Fillable LB 0489 LB-0489 Lb0489 Rev6.11.15.pmd (State of Tennessee)

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LB 0489 LB-0489 Lb0489 Rev6.11.15.pmd (State of Tennessee)

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SEPARATION NOTICE
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
Discharge
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
Severance Pay
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
Law
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)
(mm/dd/yyyy)
Amount $
______________
First Middle Initial Last
(mm/dd/yyyy)
In the amount of $ _________________ for period from _________________ to _________________
(mm/dd/yyyy) (mm/dd/yyyy)
If other than lack of work, explain the circumstances of this separation:
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 report has been handed to or mailed to the worker.
_________________________
Employer's Account Number:
Si
gnature of Official or
Representative of the Employer
who
has
first-hand
knowledge
of the separation
_________________________________________________________
Title of Person Signing Date Completed and
Released to Employee
____________________
(mm/dd/yyyy)
STATE OF TENNESSEE
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF EMPLOYMENT SECURITY
(mm/dd/yyyy) (mm/dd/yyyy)
Permanent
LB-0489 (Rev. 06-15) RDA 0063
Rule 0800-09-01-.02 of the Rules and Regulations of the Tennessee Employment Security Law, requires all
employers to furnish each separated employee with a Separation Notice, LB-0489, within 24 hours of the
employee's separation from employment.
Separation Notices do not have to be given to any employee who has been in your employ for less than a week
or who will be recalled within seven days.
Separation Notices reduce the administrative costs of processing an unemployment insurance claim and helps
make a more accurate determination of the claimant's eligibility for benefits.
Please complete the Separation Notice in its entirety.
Item 5
Check the appropriate block as to the reason the worker is separated. If the separation was for any reason
other than lack of work, give a clear explanation for the separation in the box provided. Please indicate
whether the separation is permanent or temporary, and, if temporary, when you expect to recall the worker.
Item 6
Wages in lieu of notice and severance pay affect UI
The Unemployment Insurance Accountability Act of 2012 denies unemployment insurance benefits to any
claimant who is receiving or has received wages in lieu of notice equivalent to the wages he could have
earned in that week had he been permitted to work during the period of notice. Wages in lieu of notice are
wages paid under circumstances in which the employer did not give an advance notice of separation to the
employee and are paid irrespective of the length of service of the employee.
UI benefits will also be denied to any claimant for any week in which he received a severance package that
includes an equivalent amount of salary the employee would have received if he were working during that
week.
Both the wages in lieu of notice and the severance provisions will not apply to claimants whose separating
employer filed notice of a reduction in operations, in accordance with Tennessee Employment Security law,
prior to July 1, 2012.
STATE OF TENNESSEE
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
INSTRUCTIONS
SEPARATION NOTICES
Make copies of the form, or
Visit our website tn.gov/workforce
To obtain Separation Notice forms, please:
LB-0489 (Rev. 06-15) RDA 0063
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LB 0489 LB-0489 Lb0489 Rev6.11.15.pmd (State of Tennessee)

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Completed 18 July 2020

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