Form Lb-0487 - Joint Low Earnings And Claim For Benefits For Partial Unemployment Page 2
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1
2INSTRUCTIONS FOR SUBMITTING A PARTIAL CLAIM
TO THE TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
FILE A PARTIAL WHEN:
Employee worked less than four (4) full days, and
Total of Gross Wages, Voluntary Loss, Holiday and Vacation Pay is less than $275, and
There is reasonable assurance that future work will become available for this employee.
EMPLOYER ENTERS:
ITEMS 1 - 11
Claimant Information.
ITEM 12
Payroll Information.
Week Ending Date - MM/DD/YY - This must be a Saturday date.
Hours Worked.
Gross Wages (Earned Sunday through Saturday midnight)
If Employer’s pay period ends on a day other than Saturday, adjust reported Gross Wages to a Sunday through
Saturday period. Do not combine with Voluntary Loss, Holiday or Vacation Pay.
Voluntary Loss (Dollar amount of work declined by the worker - “work available but worker declined.”)
Holiday Pay (Dollar amount. Report if worker will return to work within 21 days of the Week Ending Date.)
Vacation Pay (Dollar amount. Report if worker will return to work within 21 days of the Week Ending Date.)
ITEM 13
Most recent date employee worked.
ITEM 14
Date employee expected to return to work. Estimate if necessary, but a date is required.
ITEM 15
Employer’s Name and Mailing Address.
ITEM 16
Employer’s Telephone and Email Address.
ITEM 17
TN Employer’s Account Number. This appears on the Quarterly Wage Report submitted to the state. Do not enter
Federal Tax ID Number.
ITEM 18
The Authorized Employer Representative must sign the form, then print their name and title.
The Authorized Employer Representative must be an individual other than the claimant.
WORKER ENTERS:
ITEM 19
Worker indicates if they worked for a second employer during the week of the claim.
ITEM 20
If YES, worker reports Gross Wages for the week from this additional employer.
ITEM 21
Worker indicates location and duration of out-of-state or federal government work.
ITEM 22
Worker indicates employer and amounts of retirement or pension income.
Social Security is not reportable.
ITEM 23
Worker indicates start date - Month and Year - with primary employer submitting the claim.
ITEM 24
Worker dates and signs the claim form.
COMPLETING AND SUBMITTING THE FORM:
• Employer verifies form is complete, accurate and readable. Incomplete or unreadable claims will be returned.
• Fax form to 615-253-0807 or backup fax at 615-253-7550, or
• Email form as an attachment to Paper.Partials@tn.gov, or
• If over 20 claims in a week, mail to:
ATTN: Paper Partials
TN Dept of Labor and Workforce Development
P. O. Box 280870
Nashville, TN 37228-0870
• If 50 or more claims in a week, automated partials must be submitted.
Go to our website https://tn.gov/workforce/article/aps-automated-partial-system for information on using the Automated Partial System
(APS).
• Additional copies of the Paper Partial Claim form can be downloaded at
• The employer is the responsible party in submitting paper partial claims. Inquiries regarding submitted claims or how to complete
claims should be sent by the EMPLOYER ONLY to Paper.Partials@tn.gov.
LB-0487 (Rev. 08-15) Page 2 of 2
RDA 2271
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