GA Separation Notice Template 2005-2022

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. 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. Signature of Official Employee of the Employer or authorized agent for the employer 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 CAREER CENTER IF YOU FILE A CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS. SEE REVERSE SIDE FOR ADDITIONAL INFORMATION. DOL-800 R-8/05 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 filed. Item 1. 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 3 500. 00 in your employ YES NO If NO how much Average Weekly Wage Employer s Name Ga. D. This report has been handed to or mailed to the worker. Telephone No. Area Code Number 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 the same information on a DOL-1199FF you may attach a copy of this form DOL-800 as a part of your response. 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. Item 6. Check the appropriate block YES or NO to indicate whether this employee earned at least 3 500. 00 in your employ. 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. 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 officer 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 benefits 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 fined not more than 1 000. 00 or shall be subject to both such fine and imprisonment. Each such act shall constitute a separate offense. 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 department 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..