Free lb0487R.01.12.07.pmd - Tennessee

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TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT UNEMPLOYMENT COMPENSATION DIVISION

JOINT LOW EARNINGS and CLAIM for BENEFITS for PARTIAL UNEMPLOYMENT
1. Name of Claimant (First) (Middle or Maiden) (Last) 2. Social Security Number

3. Mailing Address (Street, RFD, or P. O. Box)

(City)

(State)

(Zip Code)

(County of Residence)

4. Claimant's Area Code and Phone Number

5. Sex M F

6. Date of Birth
month day year

7. Race

8. U.S. Citizen? Yes No

PAYROLL INFORMATION
9. During the week or weeks covered by this report this worker worked less than full-time due to lack of work and earned the amount indicated below:
Payroll Week-Ending Date Hours Worked Gross Earnings Voluntary Loss Holiday Pay Vacation Pay

Payroll Week-Ending Date

Hours Worked

Gross Earnings

Voluntary Loss

Holiday Pay

Vacation Pay

10. Last day/date employee worked _______________________________ 11. Date this employee is expected to return to work ____________________ 12. Employer's Name ______________________________________________ Mailing Address _______________________________________________ _____________________________________________________________ _________________________________________________________ 13. Employer's Email Address ___________________________________

14. Employer Account Number

15. Authorized Employer Representative ___________________________________
(Signature and Title)

___________________________________
(Area Code) (Telephone Number)

WORKER'S STATEMENT
During the week or weeks covered by this report I was able to work and available for full-time work. I hereby file a claim for benefits for partial unemployment for the week or weeks covered by this report (less week of waiting period) under the provisions of the Tennessee Employment Security Act.
16. During the above week did you work or earn wages from any employer other than the one listed above? 17. If Yes, what was your gross pay for week (1) $ ___________________ (2) $ ___________________ . NO YES NO

18. Have you been paid wages by an out-of-state employer or the federal government within the last 18 months? YES

If YES, State _______________, Dates employed ______________ State _______________, Dates employed ______________ 19. Have you filed for or are you receiving any kind of retirement or pension, excluding Social Security? YES NO

20. How long have you worked for this employer? _________________________________________________________________ I understand that the law provides a penalty for false statements to obtain or increase benefits. I request a determination of my entitlement to benefits. ____________________ ___________________________________________
(Date Signed by Worker) (Worker's Signature)

A claim for a week of some earnings must be mailed or delivered to the local unemployment claims office within fourteen (14) days of the week-ending date that appears on the claim form. A claim for a week of no earnings must be mailed or delivered to the local office within seven (7) days of the week-ending date that appears on the claim form. Information contained in your file may be released to other government agencies, as required by law.
LB-0487 (Rev. 01/07) RDA N/A

INSTRUCTIONS FOR SUBMITTING A PARTIAL CLAIM to the Tennessee Department of Labor and Workforce Development
FILE A PARTIAL WHEN: Employees work less than four (4) full days or Earnings total less than Weekly Benefit Amount

EMPLOYER ENTERS:

ITEMS 1 THROUGH 8 ITEM 9

Claimant Information Payroll Information Payroll Week Ending Date Hours Worked Wages (earned Sunday to Saturday midnight) If your pay period ends on a day other than Saturday, the Department will adjust the week ending to the following Saturday. Voluntary Loss (work declined by the worker) Holiday Pay (reportable the week the holiday occurs) Vacation Pay (reportable if for the same period)

ITEM 10 ITEM 11 ITEM 12 ITEM 13 ITEM 14 ITEM 15

Last Date Worked Date Returned to Work Employer Name and Mailing Address Employer's Email Address Employer Account Number Authorized Signature, Title, Phone Number

WORKER ENTERS:

ITEM 16-17 ITEM 18 ITEM 19 ITEM 20

Other Earnings (wages from other work the same week) Out-of-State or Federal Employment Information Retirement Pay Information Duration of Employment Date (must be later than the week ending being claimed) Signature

WHEN COMPLETING THE FORM: Verify the Social Security Number and the worker's current address. File up to two (2) weeks on one form (must be consecutive weeks). Submit claims for weeks of total unemployment within seven (7) days following the week of unemployment. Submit the forms to the local Labor and Workforce Development office.
Contact the local Labor and Workforce Development Office to obtain additional forms. You may also go to www.tennessee.gov/labor-wfd/ and access "Forms" and go to "Unemployment Insurance Forms, Employers," and scroll to Joint Low Earnings and Claim for Benefits for Partial Unemployment.
(R.1/07)