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.