Form Lb-0490 - Mass Separation Notice printable pdf download

Form Lb-0490 - Mass Separation Notice

STATE OF TENNESSEE

DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

MASS SEPARATION NOTICE

(To be used only for lack of work separations)

Date _________________________, 20 _______ on _________________________, 20 _______

(date of notice)

(last day worked)

temporarily*

We permanently ceased to employ the following workers:

Worker’s Name

Social Security No.

Date Entered Employ

Occupation

Remarks

*If temporary separation give probable duration in “REMARKS” COLUMN.

All of above workers worked at

_______________________________________________________________________________

(where work performed)

o Yes

o No

Was separation caused by lack of work?

Employer’s

Employer ___________________________________________

Address ______________________________________________

Employer Account Number _____________________________

By __________________________ Title ___________________

To be used only by arrangement with representatives of the Department of Labor and Workforce Development.

LB-0490 (R8/00)

Form Lb-0490 - Mass Separation Notice