Free lb0490R505.pmd - Tennessee

STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

MASS SEPARATION NOTICE
(To be used only for lack of work separations)
Date of notice __________________________ (month, day, year) Last day worked _________________________ (month, day, year)

We

permanently

temporarily*

ceased to employ the following workers:

*If temporary separation give probable duration in "REMARKS" COLUMN.
First Worker's Name MI Last Social Security Number Date Entered Employ Occupation Remarks

All of above workers worked at (where work performed) ___________________________________________________________ Was separation caused by lack of work? YES NO
Employer Account Number __________________

Employer Name ____________________________________________________ Employer's Address

Street/P O Box __________________________________________________________________________ City _________________________________ State _____ Zip Code _____________________

Employer Representative _________________________________________ Area Code/Phone Number _______________________________ E-Mail Address ____________________________________
LB-0490 (R5/05)

Title ________________________________________

Ext. _________

Signature of Employer Rep ___________________________________

To be used only by arrangement with representatives of the Department of Labor and Workforce Development.