Form Lb-0487 - Joint Low Earnings And Claim For Benefits For Partial Unemployment
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2TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF EMPLOYMENT SECURITY
JOINT LOW EARNINGS REPORT AND CLAIM FOR BENEFITS FOR PARTIAL UNEMPLOYMENT
CLAIMANT INFORMATION (EMPLOYER COMPLETES)
1. Name of Claimant - First
Middle or Maiden
Last
2. Social Security Number
3. Mailing Address -
4. County of Residence
Street, RFD, or P. O. Box
City
State
Zip Code
5. Claimant’s Area Code and Phone Number 6. Sex
7. Date of Birth (mm/dd/yyyy)
8. Race
M
F
9. Are you a U.S. Citizen? YES
NO 10. Address Change? YES
NO 11. Phone Number Change? YES
NO
PAYROLL INFORMATION (EMPLOYER COMPLETES)
12.During the week covered by this report this worker worked less than full-time due to lack of work and earned the amount indicated
below: (Week ending dates are always on a Saturday.)
Week Ending Date
Hours Worked
Gross Wages ($)
Voluntary Loss ($)
Holiday Pay ($)
Vacation Pay ($)
(mm/dd/yy)
0
17.TN Employer Account Number __ __ __ __ - __ __ __
13.Most recent date employee worked ___________________________
18.Signature of Authorized Employer Representative
14.Date this employee is expected to return to work ____________________
15.Employer’s Name ___________________________________________
_______________________________________
Print Name of Authorized Representative
Mailing Address
____________________________________________
____________________________________________
_______________________________________
16.Employer’s Telephone Number _______________________________
Title of Authorized Representative
Employer’s Email Address ___________________________________
_______________________________________
WORKER’S STATEMENT (WORKER COMPLETES)
During the week covered by this report I was able to work and available for full-time work. I hereby file a claim for benefits for
partial unemployment for the week covered by this report (less week of waiting period) under the provisions of the Tennessee
Employment Security Act.
19. During the above week did you work or earn wages from any employer other than the one listed above?
YES
NO
20. If YES, what was your gross pay for week? $ ___________________
21. Have you been paid wages by an out-of-state employer or the federal government within the last 18 months? YES
NO
If YES, State _______________, Dates employed __________________ State _______________, Dates employed __________________
22. Have you filed for or are you receiving any kind of retirement or pension, excluding Social Security?
YES
NO
If YES, Employer Name ____________________________________________________
Monthly amount $ _________________
23. Start date with primary employer (employer shown in number 15)
Month ________________________
Year _____________
I understand that the law provides a penalty for false statements to obtain or increase benefits. I request a determination of
my entitlement to benefits.
24. Date signed by worker ____________________
Worker’s signature _________________________________________
Claims must be received by the Partial Claims Office within eleven (11) days of the week ending date being filed.
Claims can be faxed to 615-253-0807 or 615-253-7550. They can be emailed as attachments to Paper.Partials@tn.gov. Twenty (20)
or more claims in a week must be mailed. The mailing address is Attn: Paper Partials, TN Dept. of Labor and Workforce Development,
P. O. Box 280870, Nashville TN 37228-0870. Information contained in claimant’s file may be released to other government
agencies, as required by law. Inquiries regarding paper partial claims should be sent by the employer only to Paper.Partials@tn.gov.
IMPORTANT: All questions must be completed. Incomplete or illegible claims will be returned to the employer.
LB-0487 (Rev. 08-15)
Page 1 of 2. Page 2 provides instructions.
RDA 2271
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