Form Lb-0487 - Joint Low Earnings And Claim For Benefits For Partial Unemployment
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TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT UNEMPLOYMENT COMPENSATION DIVISION
JOINT LOW EARNINGS and CLAIM for BENEFITS for PARTIAL UNEMPLOYMENT
1. Name of Claimant (First)
(Middle or Maiden) (Last)
2. Social Security Number
3. Mailing Address (Street, RFD, or P. O. Box)
(City)
(State)
(Zip Code)
(County of Residence)
4. Claimant’s Area Code and Phone Number
5. Sex
6. Date of Birth
7. Race
8. U.S. Citizen?
M
F
Yes
No
month
day
year
PAYROLL INFORMATION
9. During the week or weeks covered by this report this worker worked less than full-time due to lack of work and earned the amount
indicated below:
Payroll Week-Ending Date
Hours Worked
Gross Earnings
Voluntary Loss
Holiday Pay
Vacation Pay
Payroll Week-Ending Date
Hours Worked
Gross Earnings
Voluntary Loss
Holiday Pay
Vacation Pay
10. Last day/date employee worked _______________________________
14. Employer Account Number
11. Date this employee is expected to return to work ____________________
12. Employer’s Name ______________________________________________
15. Authorized Employer Representative
Mailing Address _______________________________________________
___________________________________
(Signature and Title)
_____________________________________________________________
_________________________________________________________
___________________________________
(Area Code)
(Telephone Number)
13. Employer’s Email Address ___________________________________
WORKER’S STATEMENT
During the week or weeks 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 or weeks covered by this report (less week of waiting period) under the provisions of the
Tennessee Employment Security Act.
16. During the above week did you work or earn wages from any employer other than the one listed above?
YES
NO
17. If Yes, what was your gross pay for week (1) $ ___________________ (2) $ ___________________ .
18. 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 ______________
19. Have you filed for or are you receiving any kind of retirement or pension, excluding Social Security?
YES
NO
20. How long have you worked for this employer? _________________________________________________________________
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.
____________________
___________________________________________
(Date Signed by Worker)
(Worker’s Signature)
A claim for a week of some earnings must be mailed or delivered to the local unemployment claims office within fourteen (14) days of the
week-ending date that appears on the claim form.
A claim for a week of no earnings must be mailed or delivered to the local office within seven (7) days of the week-ending date that appears
on the claim form.
Information contained in your file may be released to other government agencies, as required by law.
LB-0487 (Rev. 01/07)
RDA N/A
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