Fillable Form Lb-0489 - Separation Notice printable pdf download

STATE OF TENNESSEE

DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

DIVISION OF EMPLOYMENT SECURITY

SEPARATION NOTICE

1. Employee's Name: _________________________________________________

2. SSN _____________________

First

Middle Initial

Last

3. Last Employed: From: _______________ to _______________

Occupation: ____________________________________

(mm/dd/yy)

4. Where was work performed? ____________________________________________________________________________

5. Reason for Separation:

Lack of Work

Discharge

Quit

If lack of work, indicate if layoff is

Permanent

Temporary

If temporary, when do you expect to recall this individual? Date ____________

(mm/dd/yy)

If temporary, report any vacation pay that will be paid.

Week Ending Date ____________

Amount _____________

(mm/dd/yy)

If layoff is indefinite vacation pay should not be reported.

If other than lack of work, explain the circumstances of this separation:

EMPLOYER'S ACCOUNT NUMBER

Employer's

Name: _____________________________________________

Address where additional information may be obtained:

(Number shown on State Quarterly Wage Report (LB-0851) and

Premium Report (LB-0456)

___________________________________________________

I certify that the above worker has been separated from work

Zip

City: ___________________ State: ____ Code: ______________

and the information furnished hereon is true and correct.

This report has been handed to or mailed to the worker.

Employer's

Signature of Official or Representative of the Employer

Telephone Number: _______________________ _________

who has first-hand knowledge of the separation.

(Area Code) (Number)

(Ext)

Employer's E-Mail

Address

_________________________________________

Title of Person Signing

NOTICE TO EMPLOYER

Within 24 hours of the time of separation, you are required

by Rule 0800-09-01 of the Tennessee Employment Security

Date Completed and Released to Employee

Law 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

LB-0810, please give complete information in your response.

(mm/dd/yy)

NOTICE TO EMPLOYEE

IF YOU ARE FILING A CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS BY TELEPHONE OR INTERNET YOU MAY BE

INSTRUCTED TO MAIL OR FAX THE SEPARATION NOTICE TO THE TENNESSEE CLAIMS CENTER. IF YOU ARE FILING A

CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS IN-PERSON PLEASE TAKE THIS NOTICE TO THE LABOR AND

WORKFORCE DEVELOPMENT OFFICE.

LB-0489 (Rev. 08-09)

RDA 0063

Form Lb-0489 - Separation Notice

Related Articles

Related forms

Related Categories