in the amount of $ for period from to
State of Georgia
Department of Labor
SEPARATION NOTICE
1. Employee's Name 2. SSN
Employer's Name
Mailing Address
State Zip Code
City
Employer's
Telephone No.
NOTICE TO EMPLOYER
NOTICE TO EMPLOYEE
OCGA SECTION 34-8-190(c) OF THE EMPLOYMENT SECURITY LAW REQUIRES THAT YOU TAKE
THIS NOTICE TO THE GEORGIA DEPARTMENT OF LABOR FIELD SERVICE OFFICE IF YOU FILE A
CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS.
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DOL-800 (R-02-24)
I CERTIFY that the above worker has been separated from work
and the information furnished hereon is true and correct. This
report has been handed to or mailed to the worker.
Signature of Ocial, Employee of the Employer
or authorized agent for the employer
Date Completed and Released to Employee
Title of Person Signing
GA D. O. L. Account Number
At the time of separation, you are required by the Employment Security
Law, OCGA Section 34-8-190(c), to provide the employee with this
document, properly executed, giving the reasons for separation. If you
subsequently receive a request for separation information, you may
attach a copy of this form (DOL-800) as a part of your response.
(Area Code)
(Number)
6. Did this employee earn at least $9,490.00 in your employ? YES NO If NO, how much? $
a. LACK OF WORK
4. REASON FOR SEPARATION:
a. State any other name(s) under which employee worked.
3. Period of Last Employment: From To
b. If for other than lack of work, state fully and clearly the circumstances of the separation:
per month % of contributions paid by employer
5. Employee received payment for: (Severance Pay, Separation Pay, Wages-In-Lieu of Notice, bonus, prot sharing, etc.)
(DO NOT include vacation pay or earned wages)
(type of payment)
Date above payment(s) was/will be issued to employee
IF EMPLOYEE RETIRED, furnish amount of retirement pay and what percentage of contributions were paid by the employer.
Average Weekly Wage $
PRINT
CLEAR
INSTRUCTIONS TO EMPLOYER FOR COMPLETION
OF THIS SEPARATION NOTICE
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 employer-led
claims (partial) or mass separation (DOL-402) notices are led.
Item 1. Enter employee’s name as it appears on your records. If it is dierent 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 accuracy.
Item 3. Enter the dates of employee’s most recent work period.
Item 4. 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 $9,490.00 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 regarding a potential claim.
GA DOL Account Number Employer’s 8-digit state account number assigned by GDOL.
Your state DOL Unemployment Insurance Account Number as it appears on your Quarterly Tax and Wage Report.
Signature. This notice must be signed by an ocer 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 should be dated and delivered to the separated employee in electronic or hard copy format.
OCGA Section 34-8-256(b)
PENALTY FOR OFFENSES BY EMPLOYERS. “Any employing unit or any ocer 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 benets 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 ned not more than $1,000.00
or shall be subject to both such ne and imprisonment. Each such act shall constitute a separate oense.”
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.”
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DOL-800 (R-02-24)
EMPLOYER NOTIFICATION TO EMPLOYEES OF THE
AVAILABILITY OF UNEMPLOYMENT COMPENSATION
Unemployment Insurance (UI) benets are available to workers who are unemployed and who meet the state UI eligibility
laws. You may le a UI claim the rst week that your employment stops or your work hours are reduced.
For assistance or more information about ling a UI claim visit the Georgia Department of Labor’s website at dol.georgia.gov.
You will need to provide the following information in order for the state to process your claim:
• Your legal name as it appears on your Social Security card
• Social Security Number
• Georgia Driver’s License, if applicable
• Work authorization documents, if you are not a U.S. citizen
• Bank’s routing number and your account number, if you want to receive your benet payments via direct deposit
• Work history information for the last 18 months, to include your separation notice, if provided by your employer
You can le your claim online using any Internet accessible device. Follow these steps to le your claim online:
1. Go to dol.georgia.gov.
2. Select Apply for Unemployment Benets.
3. Answer the questions completely.
4. Download and read the UI Claimant Handbook. Information in this handbook provides detailed instructions regarding
the unemployment insurance (UI) program and the “Next Steps” to follow after submitting your claim.
5. Record your Conrmation Number. A conrmation email will be sent to the email address provided when completing
the claim application. (If you do not receive a conrmation number, the application was not successfully completed.
It remains on the system for 24 hours. Log in again and make sure you select FINISH to receive a conrmation number.)
If you have questions about the status of your claim, you can check the status of your claim online at dol.georgia.gov
by using My UI (Check My UI Claim Status).
For assistance, contact UI Customer Service at 1.877.709.8185 Monday–Friday, 8:00 a.m. – 4:30 p.m. EST or email Customer.
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