(Page 1 of 2)

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Stote of Georgia
Depatment of Labor
SEPARATION NOTICE
(DOL·800)

SHAY D HATCHER

1. Employee's Name

SOP IV01B·OOQ1
Attachment I
Rev.12/01 /99

2. S.S. No.

:i,;,w•u •

¥

a. State any other name(s) under which employee worked _______________________
s"""t _1'"'"2'"''-2-'-o-'-o-'-o ______
3. Period of Last Employment: From ___M__a_.y.....,._1�,____
1 .....
9__
97_____ To _......,_A_u_g�u....
4. REASON FOR SEPARATION:
a. LACK OF WORK

D

b. If for other than lack of work, state fully and clearly the circumstances of the separation:
Terminated for misconduct.

5. Employee received payment for: (Severance Pay, Separation Pay, Wages-In-Lieu of Notice, bonus, profit sharing,
etc.) (DO NOT include vacation pay or earned wages)
---.,---,---�-,--- in the amount of$

for period from

(typo al paym�nti

to

Date above payment(s) was/will be issued to employee----------IF EMPLOYEE RETIRED, furnish amount of retirement pay and what percentage of contributions were paid by the
employer.
% of contributions paid by employer.
per month
6

.

Did this employee earn at least $2 500 00 in your employ? YES i;;xJ No i:;;;;J
EMPLOYER'S NAME: GEORG A DEPARTMENT OF CORRECTIONS
Fucility tr-ame)

HAYS STATE PRISON

c/o R. E. HARRINGTON
Address P. O. BOX /24086
City ATLANTA

State GA

Zip Code

31139-1086

R. E. HAR'IINGTON'S Tttlephone t\,;mh�rn;

Fnx Numti�r;

1-800 241-b341, 770-379 9':>60

770-396-9027

NOTICE TO EI/.PLOYER
At the t:mc of scpHrAtk,n, you arc roqJired 1,y the Employment
Security Law. OCGA Section 34·6-190101, to provide the employee
with this document, propc•ly t,)(fJCUted, giving the rt3ason6 fer
separation.
If you eubeeqt..ent\•1 rucaive a roqu11st for th,-, same
informetlc,n on R OOL 403FF, yr;u may attach a copy at this form
IDOUIOO) a• part of your res;,onsr..

If NO I how much $

Gn. O.O.L. A.:count Number
110094-00
INumbttr shown on Employer's duartarly Tax and Wage Report. Form
DOL-4.I
I CERTIFY that tho above worker has been sapurnted Irani wor� ann
tha lntormHtion furnished hereon is tru'l ttnd correct. This report hne
bear, handed to or mailed to the wor�er.

:?<Na'�/�)

Signature of Of�I. Employee of the Employer
or authoriznd agent for the employer

Personnel Manager

Titlo of Person Signing

August 14 I 2000

Date Completed and l'\e!oaBlld to Emp!oytio

NOTICE TO EM PLOYEE
OCGA SECTION 34·8·190lc), OF THE EMPLOYMENT SECURITY LAW REQUIRES THAT YOU TAKE THIS NOTICE TO THE GEORGIA
DEPARTMENT OF LABOR FIELD SERVICES OFFICE IF YOU FILE A CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS.

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GA DEPARTMENT OF CORRECTIONS
HAYS STATE PRISON
PO BOX 668
TRION, GA 30753
(706) 857-0400 OR FAX 1706) 857-0624
!lilly lompkms, Warden

July 28 2000

Shay Hatcher
2103 Southern Street
Rome, GA 30161
This 1s to advise you of my intention to take 1ha following adverse action agamst you A copy of the chargels) tor which this ac11on Js proposoo ,s attached
• D1sn11ssel from employment etlect,ve August I 2, 2000
You have the right to respond to the Comm1ss1oner's Des1gnee for Adverse Action w1th1n 10 calendar daya from the, date of receipt of the charge(s) or
raa�on(s) given for the adverse ac\ton Your response may be m wttttng, 1n person, or both If you wish to appear 1n person, It must be et an agreed upon
time between 8 00 e m to 4 30 p m , Monday through Frtdey In order to cootdtnete your written response, personal response or both, please call the
iollowmg person designated to consider vour response
DOUG LAUDERDALE COMMISSIONER'S OESIGNEE FOR ADVERSE ACTION
2 MARTIN LUTHER KING, JR DRIVE
SUITE 756, EAST TOWER
ATLANTA, GA 30334
(4041 656·6348 or FAX (404) 657·4317
You may submit affidavits or othar evidence m support of your written or personal response to this proposed adverw action
II you fall to respond to the Comm1ssroner's designee wuhin 10 calendar days as set forth In this notice, you will have waived all further appeal nghts, 111cJud1ng
any appeal to the State Personnel Board As a result of a fo1lure to reepond, the adverse action as proposed w,11 become final and affect,va on the above
spec1f1ed dote without further notice

Employee'sStgre
Acknowledges Receipt Only

cc Fac1Jit1es D1v1s1on 011ector
North lleg10ti Direotllr
Department Personnel Director
Director of C•rt1f1cauon 01v1s1on · POST Council
. L&gal Office Representellve
Comm1ss1oner' s Deslgnae for Adverse Action
CPA Adverse Actton Coordinator
Local Personnel File

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Date