Form Lb-0489 - Separation Notice
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2STATE OF TENNESSEE
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF EMPLOYMENT SECURITY
SEPARATION NOTICE
1. Employee's Name: ________________________________________________________ 2. SSN _____________________
First
Middle Initial
Last
3. Last Employed: From: _______________ to _______________
Occupation: _____________________________________
(mm/dd/yy)
(mm/dd/yy)
4. Where was work performed? _____________________________________________________________________________
5. Reason for Separation:
Lack of Work
Discharge
Quit
If lack of work, indicate if layoff is
Permanent
Temporary - Recall Date ______________
(mm/dd/yy)
If temporary, report any vacation pay that will be paid.
Week Ending Date _____________
Amount $ ______________
(mm/dd/yy)
If layoff is indefinite vacation pay should not be reported.
6. Employee received:
Wages in Lieu of Notice
Severance Pay
In the amount of $ _________________ for period from _________________ to _________________
(mm/dd/yy)
(mm/dd/yy)
If other than lack of work, explain the circumstances of this separation:
Employer's Name:
Address where additional information may be obtained:
Employer's Telephone Number:
Employer's Email Address:
Number shown on State Quarterly Wage Report (LB-0851) and
Employer's Account Number:
Premium Report (LB-0456)
I certify that the above worker has been separated from work and the information furnished hereon is true and correct. This report
has been handed to or mailed to the worker.
Signature of Official or Representative of the Employer
Title of Person Signing
Date Completed and Released
who has first-hand knowledge of the separation
to Employee
__________________________________________
_________________________
____________________
(mm/dd/yy)
NOTICE TO EMPLOYER
Within 24 hours of the time of separation, you are required by Rule 0800-09-01-.02 of the Tennessee Employment Security Law
to provide the employee with this document, properly executed, giving the reasons for separation. If you subsequently receive a
time sensitive request for separation information for the same information please give complete information in your response.
NOTICE TO EMPLOYEE
YOU MAY BE INSTRUCTED TO MAIL OR FAX THE SEPARATION NOTICE TO TENNESSEE CLAIMS OPERATIONS IF YOU FILE A
CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS.
LB-0489 (Rev. 06-15)
RDA 0063
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