Form Dol-402 - Mass Separation Notice printable pdf download

Form Dol-402 - Mass Separation Notice

GEORGIA DEPARTMENT OF LABOR

148 International Boulevard, N. E.

Atlanta, Georgia 30303-1751

Attached are

Pages of DOL-402A

MASS SEPARATION NOTICE

Date

Account

Number

1. Employer’s Name

Address

INSTRUCTIONS TO EMPLOYER

WHEN 25 OR MORE EMPLOYEES SEPARATE (1) on the same day (2) for the same reason, and (3) from the same

establishment, complete this form and DOL-402A.

Mail two copies of this notice to the nearest Employment Office, within 24 hours after date of separation, in order that

steps may be taken to protect the unemployment insurance rights of the unemployed workers.

2. The

workers whose names are listed and attached herewith on Form DOL-402A are unemployed, able

TOTAL NUMBER

to work, and available for work; they register for work and claim benefits under the Georgia Employment Security Law.

Of these workers

are totally unemployed.

NUMBER

are partially unemployed.

NUMBER

are intermittently unemployed.

NUMBER

3. Reason for separation (Check one):

Lay-off because of lack of work.

Other reasons (give details briefly)

4. Last day worked

MONTH

DAY

YEAR

5. The probable duration of the period of unemployment will be

6. Address of work place of persons

listed if different from above

7. I certify that the information entered above and on all attached sheets is true and correct.

8. Signature

9. Title

CAUTION: This Notice is incomplete unless Form DOL-402A is properly filled out and attached.

DOL-402 (R-7/90)

Form Dol-402 - Mass Separation Notice