SOP 104.62-att-2: Instructions to Employer for Completion of Separation Notice

SOP 104.62
Attachment 2

7/10/18

|INSTRUCTIONS TO EMPLOYER FOR COMPLETION
OF SEPARATION NOTICE|Col2|
|---|---|
|In accordance with the Employment Security Law, OCGA Section 34-8-190(c) and Rules pursuant thereto, a
Separation Notice must be completed for each worker who leaves your employment, regardless of the reason
for the separation. This notice shall be used where the employer-employee relationship is terminated and
shall not be used when partial (DOL-408) or mass separation (DOL-402) notices are filed.|In accordance with the Employment Security Law, OCGA Section 34-8-190(c) and Rules pursuant thereto, a
Separation Notice must be completed for each worker who leaves your employment, regardless of the reason
for the separation. This notice shall be used where the employer-employee relationship is terminated and
shall not be used when partial (DOL-408) or mass separation (DOL-402) notices are filed.|
|Item 1.|Enter employee’s name as it appears on your records. If it is different from the name
appearing on the employee’s Social Security Card, report both names.|
|Item 2.|Enter the employee’s Social Security Number. Verify for correctness.|
|Item 3.|Enter the dates of employee’s most recent work period.|
|Item 4.|Reason for Separation:
a. If the reason for separation is for “LACK OF WORK”, check box indicated.
b. If the reason for separation is OTHER THAN “lack of work”, give complete
details about the separation in space provided. If needed, add a separate sheet of
paper.|
|Item 5.|If any type payment, (i.e., Separation Pay, Wages-in-lieu of Notice, etc.) was made,
indicate the type of payment and the period for which payment was made beyond the
last day. Give the date on which the payment was/will be issued to the employee. DO
NOT include vacation pay or earned wages.|
|Item 6.|Check the appropriate block YES or NO to indicate whether this employee earned at
least $3,000.00 in your employ. If you check NO, enter amount earned in your
employ. Give average weekly wage (without overtime) at the time of separation.|
|EMPLOYER'S
NAME:
|Give full name of employer under which the business is operated.|
|ADDRESS:|Give full mailing address of the employer where communications are to be sent in
regard to any potential claim.|
|Georgia's DOL
Account Number:|Your state DOL Unemployment Insurance Account Number as it appears on your
Quarterly Tax and Wage Report, Form DOL-4. (110094-00)|
|Signature:|This notice must be signed by an officer or employee of the employer or authorized
agent for the employer, and this person’s title or position held with the employer
must be shown.|
|Date:|This notice must be dated as of the date it is handed to the worker. If the employee is
no longer available at the time employment ceases, mail this form (DOL-800) to the
employee’s last known address and enter date the form is mailed.|

OCGA Section 34-8-256(b)
PENALTY FOR OFFENSES BY EMPLOYERS. “Any employing unit or any officer or agent of an employing unit or any other person who
knowingly makes a false statement or representation or who knowingly fails to disclose a material fact in order to prevent or reduce the payment of
benefits to any individual entitled thereto or to avoid becoming or remaining subject to this chapter or to avoid or reduce any contribution or other
payment required from an employing unit under this chapter or who willfully fails or refuses to make any such contributions or other payment or to
furnish any reports required under this chapter or to produce or permit the inspection or copying of records as required under this chapter shall upon
conviction be guilty of a misdemeanor and shall be punished by imprisonment not to exceed one year or fined not more than $1,000.00 or shall be
subject to both such fine and imprisonment. Each such act shall constitute a separate offense.”

OCGA Section 34-8-122(a)
PRIVILEGED STATUS OF LETTERS, REPORTS, ETC. RELATING TO ADMINISTRATION OF CHAPTER.
“”All letters, reports, communications, or any other matters, either oral or written, from the employer or employee to each other or to the department or
any of its agents, representatives, or employees, which letters, reports, or other communications shall have been written, sent, delivered, or made in
connection with the requirements of the administration of this chapter, shall be absolutely privileged and shall not be made the subject matter or basis
for any action for slander or libel in any court of the State of Georgia.”

Retention Schedule: This form is a reference document only and does not have to be retained.

DOL-800 (R-5/99)