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) $7,300 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-6/19)