STATE OF TENNESSEEDEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENTDIVISION OF EMPLOYMENT SECURITYSEPARATION NOTICE1. Employee's Name: ________________________________________ _________ 2. SSN _____________________3. Last Employed: From: _______________ to _______________ Occupation: ____________________________________4. Where was work performed? ________________________________________ ____________________________________5. Reason for Separation: Lack of Work Discharge QuitIf lack of work, indicate if layoff is Permanent TemporaryIf temporary, when do you expect to recall this individual? Date ____________If temporary, report any vacation pay that will be Ending Date ____________ Amount _____________If layoff is indefinite vacation pay should not be other than lack of work, explain the circumstances of this separation:EMPLOYER'S ACCOUNT NUMBER(Number shown on State Quarterly Wage Report (LB-0851) andPremium Report (LB-0456)I certify that the above worker has been separated from workand the information furnished hereon is true and report has been handed to or mailed to the TO EMPLOYEEIF YOU ARE FILING A CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS BY TELEPHONE OR INTERNET YOU MAY BEINSTRUCTED TO MAIL OR FAX THE SEPARATION NOTICE TO THE TENNESSEE CLAIMS CENTER. IF YOU ARE FILING ACLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS IN-PERSON PLEASE TAKE THIS NOTICE TO THE LABOR ANDWORKFORCE DEVELOPMENT TO EMPLOYERWithin 24 hours of the time of separation, you are requiredby Rule of the Tennessee Employment SecurityLaw to provide the employee with this document, properlyexecuted, giving the reasons for separation. If yousubsequently receive a request for the same information onLB-0810, please give complete information in your (Rev. 09-08)Employer'sName: ________________________________________ _____Address where additional information may be obtained:_______________________________ ____________________City: ___________________ State: ____ Code: ______________Employer'sTelephone Number: _______________________ _________Employer's E-MailAddress ________________________________________ _(Area Code) (Number)(Ext)ZipFirst Middle Initial LastSignature of Official or Representative of the Employerwho has first-hand knowledge of the of Person SigningDate Completed and Released to Employee(mm/dd/yy)(mm/dd/yy)(mm/dd/yy)(m m/dd/yy)(mm/dd/yy)TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENTINSTRUCTIONSSEPARATION NOTICESRule of the Rules and Regulations of the Tennessee Employment Security Law, requires allemployers to furnish each separated employee with a Separation Notice, LB-0489, within 24 hours of theemployee's separation from Notices do not have to be given to any employee who has been in your employ for less than a weekor who will be recalled within seven Notices reduce the administrative costs of processing an unemployment insurance claim and helpsmake a more accurate determination of the claimant's eligibility for complete the Separation Notice in its 5Check the appropriate block as to the reason the worker is separated. If the separation was for any reason otherthan lack of work, give a clear explanation for the separation in the box provided. Please indicate whether theseparation is permanent or temporary, and, if temporary, when you expect to recall the obtain Separation Notice forms, please: make copies of the form on the reverse side of these instructions, or call toll-free:1-800-344-8337 in Tennessee go to our Web Site and to Forms, Unemployment Insurance Forms- Employers, and scroll to Separation Notice, LB-0489
STATE OF TENNESSEE DEPARTMENT OF LABOR …
state of tennessee department of labor and workforce development division of employment security separation notice 1. employee's name: _____ 2.
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