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State of Georgia Department of LaborSEPARATION NOTICE 1. Employee's Name2. S. S. No.a. State any other name(s) under which employee worked. 3. Period of Last Employment: FromTo4. REASON FOR SEPARATION: a.

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Follow the steps to fill out the Fill Online form correctly.

  1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
  2. Begin by entering the employee's name in the designated field, ensuring it matches the records you have on file. If the employee has worked under a different name, please include that information as well.
  3. Input the employee’s Social Security Number accurately in the next field and verify its correctness.
  4. Indicate the period of the employee's last employment by filling out the 'From' and 'To' dates.
  5. For the reason for separation, check the box if it is due to 'LACK OF WORK.' If the separation is for another reason, provide a detailed explanation in the space allowed.
  6. Enter details regarding any payments the employee received, including types like severance pay or wages-in-lieu of notice. Specify the amounts and the relevant periods.
  7. Answer whether the employee earned at least $3,000.00 during their employment. If not, input the exact amount they earned and provide the average weekly wage.
  8. Fill in the employer’s name and address, making sure to provide the full mailing address for any communications.
  9. Input the Georgia DOL account number as shown on your Quarterly Tax and Wage Report.
  10. The form must be signed by an authorized individual, who should also include their title and the date the form is completed.

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