1. Employee's Name: ________________________________________________________ 2. SSN _____________________
3. Last Employed: From: _______________ to _______________ Occupation: _____________________________________
4. Where was work performed? _____________________________________________________________________________
5. Reason for Separation: Quit
If lack of work, indicate if layoff is
Lack of Work
Temporary - Recall Date ______________
If temporary, report any vacation pay that will be paid. Week Ending Date _____________
If layoff is indefinite vacation pay should not be reported.
Wages in Lieu of Notice
6. Employee received:
NOTICE TO EMPLOYER
Within 24 hours of the time of separation, you are required by Rule 0800-09-01-.02 of the Tennessee Employment Security
to provide the employee with this document, properly executed, giving the reasons for separation. If you subsequently receive a time
sensitive request for separation information for the same information please give complete information in your response.
NOTICE TO EMPLOYEE
YOU MAY BE INSTRUCTED TO MAIL OR FAX THE SEPARATION NOTICE TO TENNESSEE CLAIMS OPERATIONS IF YOU FILE A
CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS.
Number shown on State Quarterly Wage Report (LB-0851) and
Premium Report (LB-0456)
First Middle Initial Last
In the amount of $ _________________ for period from _________________ to _________________
If other than lack of work, explain the circumstances of this separation:
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 report has been handed to or mailed to the worker.
Employer's Account Number:
gnature of Official or
Representative of the Employer
of the separation
Title of Person Signing Date Completed and
Released to Employee
STATE OF TENNESSEE
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF EMPLOYMENT SECURITY
LB-0489 (Rev. 06-15) RDA 0063