Fillable Form Lb-0489 - Separation Notice printable pdf download

Form Lb-0489 - Separation Notice

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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: ____________________________________

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

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

6. Employee received:

Wages in Lieu of Notice

Separation Pay

Vacation Pay

In the amount of $ ________________________for period from ____________________ to ____________________

EMPLOYER'S ACCOUNT NUMBER

Employer's

Name: _______________________________________________

Address where additional information may be obtained:

_____________________________________________________

(Street or RFD)

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

Zip

Premium Report (LB-0456)

City: ___________________ State: ___ Code: _______________

I certify that the above worker has been separated from work and

Employer's

the information furnished hereon is true and correct. This report

Telephone Number: ___________________________ _________

has been handed to or mailed to the worker.

(Area Code) (Number)

(Ext)

Employer's E-Mail

Address

____________________________________________

Signature of Official or Representative of the Employer

who has first-hand knowledge of the separation.

NOTICE TO EMPLOYER

Within 24 hours of the time of separation, you are

Title of Person Signing

required by Rule 0560-1-1-02 of the Tennessee

Employment Security Law to provide the employee with

this document, properly executed, giving the reasons

for separation. If you subsequently receive a request

Date Completed and Released to Employee

for the same information on LB-0810, please give

complete information in your response.

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 CLAIM 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(R.5/06)

RDA N/A

Form Lb-0489 - Separation Notice

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