STATE OF TENNESSEE DEPARTMENT OF LABOR …

1 separation 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 Temporary - Recall Date _____If temporary, report any vacation pay that will be paid. Week Ending Date _____ Amount $ _____If layoff is indefinite vacation pay should not be Employee received: Wages in Lieu of Notice Severance PayIn the amount of $ _____ for period from _____ to _____If other than lack of work, explain the circumstances of this separation :NOTICE TO EMPLOYEEYOU MAY BE INSTRUCTED TO MAIL OR FAX THE separation NOTICE TO TENNESSEE CLAIMS OPERATIONS IF YOU FILE ACLAIM FOR UNEMPLOYMENT INSURANCE TO EMPLOYERW ithin 24 hours of the time of separation , you are required by Rule of the TENNESSEE Employment Security Lawto provide the employee with this document, properly executed, giving the reasons for separation .

2 If you subsequently receive atime sensitive request for separation information for the same information please give complete information in your (Rev. 06-15) RDA 0063 Number shown on STATE Quarterly Wage Report (LB-0851) andPremium Report (LB-0456)(mm/dd/yy)First Middle Initial Last(mm/dd/yy)(mm/dd/yy)(mm/dd/yy)(mm/dd /yy)Employer's Name:Address where additional information may be obtained: Employer's Telephone Number:Employer's Email Address:I certify that the above worker has been separated from work and the information furnished hereon is true and correct. This reporthas been handed to or mailed to the 's Account Number:Signature of Official or Representative of the Employerwho has first-hand knowledge of the separationTitle of Person SigningDate Completed and Releasedto EmployeeSTATE OF TENNESSEEDEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENTDIVISION OF EMPLOYMENT SECURITY(mm/dd/yy)(mm/dd/yy)