GEORGIA DEPARTMENT OF LABOR 
                              MASS SEPARATION NOTICE - CONTINUATION SHEET 
  
  Employer                                                                      Account Number 

                         Employee Name          Worker earned                  Separation Pay (Severance , Wages in Lieu of Notice)     
                         (List Alphabetically)  $6,600 or more                           
                                                     If NO      Retired?  Date          Avg Gross  Lump Sum Specified Period            EDW? 
 Social Security Number  Last First             Yes  Amount  Yes  No      Paid  Amount  Wkly Wage  Yes  No  From                    To  Yes  No 
                                                                                                                  
                                                                                                                  DOL-402A (R-7/18)