GEORGIA DEPARTMENT OF LABOR - MASS SEPARATION NOTICE148 Andrew Young International Blvd., N.E., Suite 700Atlanta, GA 30303-1751Email: MassSeparations@gdol.ga.gov Fax (404) 232-3199 þ Employer þ Account Number þ Street Address þ City þ State þ Zip þ TelephoneINSTRUCTIONS When 25 or more employees in one establishment are separated on the same day, for the same reason, 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 basis. (See attached instructions).1. þ What is the reason for the mass separation (check one): þ þ þ þ þ þ þ i. Date(s) of the disaster affecting your business: þ þ Separated as a result of a vacation period or planned shutdown, due to an established employer þ þ þ Yes No þ ii. Is there a paid vacation plan applicable to the employees who meet the eligibility þ Yes No þ þ þ Yes No þ þ Other reason (leave of absence with or without pay, furlough, etc. þ Specify/Explain: þ 2. þ þ þþ þ DOL-402 (R-8/18) American LegalNet, Inc. www.FormsWorkFlow.com 4. þ Does your company provide services to, for, with or on behalf of a school or educational institution þ þ Yes No þ i. If yes, are ALL these employees not working due to a lack of work because of a school þ þ Yes No þ Yes No þ Yes No þ a. If yes, what percentage of the entire retirement amount per pay period was paid by the þ þ 6. þ Address of work location: þ 7. þ I certify that the information above and on all attached pages are true and correct. þ Printed Name: Signature: þ Title: Contact Number: þ Email: þ DOL-402 (R-8/18) American LegalNet, Inc. www.FormsWorkFlow.com