Form Dol-800 - Separation Notice
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1
2State of Georgia
Print Form
Department of Labor
Clear Fields
SEPARATION NOTICE
1. Employee's
Name
-
-
2. SSN
a. State any other name(s) under which employee worked:
From
To
3. Period of Last Employment:
a. LACK OF WORK
4. REASON FOR SEPARATION:
b. If other than lack of work, state fully and clearly the circumstances of the separation. Type Below.
5. Employee received payment for: (Severance Pay, Separation Pay, Wages-In-Lieu of Notice, bonus, profit sharing, etc.)
DO NOT include vacation pay or earned wages.
type of payment
to
in the amount of $
for period from:
Date above payment(s) was/will be issued to employee:
IF EMPLOYEE RETIRED, furnish amount of retirement pay and what percentage of contributions were paid by the employer.
per month
$
% of contributions paid by employer.
NO
6. Did this employee earn at least $3,500.00 in your employ?
YES
If NO, how much? $
Average Weekly Wage:
$
Ga. DOL
Employer's
Account
Name
-
Number
(Number shown on Employer's Quarterly Tax and Wage
Address
Report, Form DOL-4.)
I CERTIFY that the above worker has been separated from
work and the information furnished hereon is true and
correct. This report has been handed to or mailed to the worker.
City
State
Zip Code
Employer's
Signature of Official, Employee of the Employer
-
(
)
Ext.
Telephone No
or authorized agent for the employer
.
NOTICE TO EMPLOYER
Title of Person Signing
At the time of separation, you are required by the Employment Security Law, OCGA
Section 34-8-190(c), to provide the employee with this document, properly executed, giving
the reasons for separation. If you subsequently receive a request for the same information
on a DOL-1199FF, you may attach a copy of this form (DOL-800) as a part of your
Date Completed and Released to Employee
response.
NOTICE TO EMPLOYEE
OCGA SECTION 34-8-190(c) OF THE EMPLOYMENT SECURITY LAW REQUIRES THAT YOU TAKE THIS NOTICE TO THE GEORGIA
DEPARTMENT OF LABOR FIELD SERVICE OFFICE IF YOU FILE A CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS.
DOL-800 (R-08/05)
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