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 partial (DOL-408)
or mass separation (DOL-402) notices are led.
Item 1. Enter employee’s name as it appears on your records. If it is dierent from the name appearing on the employee’s
Social Security Card, report both names.
Item 2. Enter the employee’s Social Security Number. Verify for correctness.
Item 3. Enter the dates of employee’s most recent work period.
Item 4. a. If the reason for separation is for “LACK OF WORK,” check box indicated.
b. If the reason for separation is OTHER THAN “lack of work,” give complete details about the
separation in space provided. If needed, add a separate sheet of paper.
Item 5. If any type payment, (i.e. Separation Pay, Wages-in-lieu of Notice, etc.) was made, indicate the type of payment
and the period for which payment was made beyond the last day. Give the date on which the payment was/will
be issued to the employee. DO NOT include vacation pay or earned wages.
Item 6. Check the appropriate block YES or NO to indicate whether this employee earned at least $7,300.00 in your em-
ploy. If you check NO, enter amount earned in your employ. Give average weekly wage (without overtime) at the
time of separation.
Employer’s Name. Give full name of employer under which the business is operated.
Address. Give full mailing address of the employer where communications are to be sent in regard to any potential
claim.
Company’s Georgia DOL Account Number. Your state DOL Unemployment Insurance Account Number as it appears on
your Quarterly Tax and Wage Report, Form DOL-4.
Signature. This notice must be signed by an ocer or employee of the employer or authorized agent for the employer,
and this person’s title or position held with the employer must be shown.
Date. This notice must be dated as of the date it is handed to the worker. If the employee is no longer available
at the time employment ceases, mail this form (DOL-800) to the employee’s last known address and enter
date the form is mailed.
OCGA Section 34-8-256(b)
PENALTY FOR OFFENSES BY EMPLOYERS. “Any employing unit or any ocer or agent of an employing unit or any other
person who knowingly makes a false statement or representation or who knowingly fails to disclose a material fact in order
to prevent or reduce the payment of benets to any individual entitled thereto or to avoid becoming or remaining subject to
this chapter or to avoid or reduce any contribution or other payment required from an employing unit under this chapter or
who willfully fails or refuses to make any such contributions or other payment or to furnish any reports required under this
chapter or to produce or permit the inspection or copying of records as required under this chapter shall upon conviction be
guilty of a misdemeanor and shall be punished by imprisonment not to exceed one year or ned not more than $1,000.00
or shall be subject to both such ne and imprisonment. Each such act shall constitute a separate oense.”
OCGA Section 34-8-122(a)
PRIVILEGED STATUS OF LETTERS, REPORTS, ETC., RELATING TO ADMINISTRATION OF CHAPTER. “All letters, reports,
communications, or any other matters, either oral or written, from the employer or employee to each other or to the de-
partment or any of its agents, representatives, or employees, which letters, reports, or other communications shall have
been written, sent, delivered, or made in connection with the requirements of the administration of this chapter, shall be
absolutely privileged and shall not be made the subject matter or basis for any action for slander or libel in any court of
the State of Georgia.”
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