Form Dol-402a - Mass Separation Notice - List Of Workers - Georgia Department Of Labor

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GEORGIA DEPARTMENT OF LABOR
MASS SEPARATION NOTICE - LIST OF WORKERS
Employer
Account Number
Severance Pay/Wages in Lieu of Notice (Paid or Being Paid)
Workers’ Names
Worker earned
Retired?
(list alphabetically)
$3,500 or more
If yes, complete and indicate period if monies are for specified period.
Social Security
Lump Sum
Specified Period?
No
Date
Avg. Gross
Last
First
Middle
Number
Yes
Amount
Yes
No
Paid
Amount
Weekly Wage
No
To
Yes
From
DOL-402A (R-8/06)

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