GEORGIA DEPARTMENT OF LABOR - MASS SEPARATION NOTICE 
               148 Andrew Young International Blvd., N.E., Suite 700
                                     Atlanta, GA  30303-1751
                                   Email: Mass_Separations@gdol.ga.gov  

Employer                                                    Account Number

Street Address                                                       City 

 State         Zip                   Telephone

                                     INSTRUCTIONS 
When 25 or more employees in one establishment are separated on the same day, for the same reason, 
and the separation is permanent, for an indefinite period or for an expected period of seven days or more, 
complete this form, and the Mass Separation List of Workers (DOL-402A).  A separate list should be completed 
for each set of employees who are separated on different days or for different reasons.  

Submit this form and the list of workers to the department within 48 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. (See attached instructions).

1. What is the reason for the mass separation (check one):

q Totally separated because of lack of work without a definite date to return to work.
q Separated because of lack of work with a definite date to return to work.
q Separated due to a natural disaster (Ex. hurricane, tornado, flood)?
         i.Date(s) of the disaster affecting your business:    ____________        _______________

q Separated as a result of a vacation period or planned shutdown, due to an established employer
  custom, practice, or policy as evidenced by the previous year or years?
         i.Was an announcement made at least 30 days prior to the scheduled period?

               q   Yes     q  No
         ii.Is there a paid vacation plan applicable to the employees who meet the eligibility

               requirements of the plan?    q  Yes     q  No
               a. If yes, have ALL these employees met the eligibility requirement?

                                   q Yes     q  No
q Other reason (leave of absence with or without pay, furlough, etc.
         Specify/Explain:   _________________________________________________________
         _______________________________________________________________________
2. What is the last day worked?  __________________________________________________________

3. What is the expected return to work date?   _______________________________________________

                                                                                         DOL-402 (R- /420)

4. Does your company provide services to, for, with or on behalf of a school or educational institution
   (this includes public and private schools or educational institutions and pre-K providers)?
   q    Yes     q  No
             i.If yes, are ALL these employees not working due to a lack of work because of a school
             closure, (e.g. Summer break, customary school vacation period or holiday recess)?
             q   Yes     q  No

5. Did any workers retire?  q Yes   q No
   i.If yes, was any deduction made from the employees paycheck orf retirement?        q  Yes    q No

             a. If yes, what percentage of the entire retirement amount per pay period was paid by the 
                employer? (Ex. Employer paid 2% of salary into retirement fund; worker paid 2% into 
                retirement fund, thus each person paid 50%).     __________%
6. Address of work location: 
   _________________________________________________________________________________
7. I certify that the information above and on all attached pages are true and correct.
   Printed Name: _________________________________      Signature: _________________________ 
   Title: __________________________________       Contact Number: _________________________ 
   Email: ____________________________________________________________________________

                               Print                   Clear

                                                                                       DOL-402 (R- /420)