Get Blank Separation Notice Ga 2024-2025

State of Georgia Department of Labor SEPARATION NOTICE 1. Employee s Name 2. SSN a. State any other name s under which employee worked. 3. Title of Person Signing Date Completed and Released to Employee OCGA SECTION 34-8-190 c OF THE EMPLOYMENT SECURITY LAW REQUIRES THAT YOU TAKE THIS NOTICE TO THE GEORGIA DEPARTMENT OF LABOR FIELD SERVICE OFFICE IF YOU FILE A CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS. Page 1 of 3 PRINT CLEAR DOL-800 R-7/21 INSTRUCTIONS TO EMPLOYER FOR COMPLETION OF THIS SEPARATION NOTICE In accordance with the Employment Security Law OCGA Section 34-8-190 c and Rules pursuant thereto a Separation Notice must be completed for each worker who leaves your employment regardless of the reason for the separation. This notice shall be used where the employer-employee relationship is terminated and shall not be used when employer-filed claims partial or mass separation DOL-402 notices are filed. Item 1. You may file a UI claim the first week that your employment stops or your work hours are reduced. For assistance or more information about filing a UI claim visit the Georgia Department of Labor s website at dol.georgia.gov. You will need to provide the following information in order for the state to process your claim Your legal name as it appears on your Social Security card Georgia Driver s License if applicable Work authorization documents if you are not a U.S. citizen Bank s routing number and your account number if you want to receive your benefit payments via direct deposit Work history information for the last 18 months to include your separation notice if provided by your employer You can file your claim online using any Internet accessible device. Period of Last Employment From To 4. REASON FOR SEPARATION a* LACK OF WORK b. If for other than lack of work state fully and clearly the circumstances of the separation 5. Employee received payment for Severance Pay Separation Pay Wages-In-Lieu of Notice bonus profit sharing etc* DO NOT include vacation pay or earned wages type of payment in the amount of for period from to Date above payment s was/will be issued to employee IF EMPLOYEE RETIRED furnish amount of retirement pay and what percentage of contributions were paid by the employer. per month of contributions paid by employer 6. Did this employee earn at least 7 300. 00 in your employ YES NO If NO how much Average Weekly Wage GA D. O. L* Account Number 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. Mailing Address City Employer s Telephone No* State Area Code Zip Code Number Signature of Official Employee of the Employer or authorized agent for the employer NOTICE TO EMPLOYER At the time of separation you are required by the Employment Security Law OCGA Section 34-8-190 c to provide the employee with this document properly executed giving the reasons for separation* If you subsequently receive a request for separation information you may attach a copy of this form DOL-800 as a part of your response.