Dol 402 Form – Fill Out and Use This PDF

GEORGIA DEPARTMENT OF LABOR - MASS SEPARATION NOTICE

148 Andrew Young International Blvd., N.E., Suite 700

Atlanta, GA 30303-1751

Fax (404) 232-3199

1. Employer								Account Number
Street Address									City
State				Zip		Telephone

INSTRUCTIONS

When 25 or more employees separate on the same day for the same reason, complete this form, IN DETAIL, and the Mass Separation-List of Workers form (DOL-402A). A separate list should be completed for each set of employees for each different reason for separation as shown below.

Fax or mail this form and the List of Workers form to the above address/number within 24 hours after the date of separation. This will ensure that claims are handled efficiently and could eliminate requests to you for information on an individual basis.

2.Reason for separation (check one):

Totally separated because of lack of work.

Separated because of lack of work with or without a definite date to return to work.

Other reason (leave of absence with or without pay, furlough, etc.)

3. Last date worked		/	/
	Month	Day	Year

4. Date of expected return to work, if any.

5. Did any workers retire? Yes		No
Was any deduction made from the employee’s paycheck for retirement? Yes						No

If yes, what percentage of the entire retirement amount per pay period was paid by the employer? (Example: Employer paid 2% of salary into retirement fund; worker paid 2% of salary into retirement fund. Therefore, each paid 50%)

6.Address of work location, if different from above.

7.I certify that the information entered above and on all attached pages is true and correct.

Signature

Title

DOL-402 (R-06/13)