Request for Separation Forms

*Please note, receiving sick pay does now disqualify individuals from receiving unemployment insurance benefits

Separation forms are mailed to the most recent employer for an individual who has established a claim for unemployment insurance benefits with the Vermont Department of Labor. Forms are mailed in order to determine the reason for the claimant’s separation.


When and When Not to Complete

Response IS NOT Required When:
  • The claimant was separated due to a lack of work
  • Did not receive any separation pay at the time of separation (vacation/wages in lieu of notice, severance pay, or sick pay), and
  • The return to work date indicated on the form is correct.

However, if any of the conditions listed below exist, the form MUST be completed and RETURNED by the due date indicated on the form. Failure to do so prevents the Department from making a proper determination on whether or not the unemployed worker is entitled to benefits.

If form is not completed and returned by the date required, the employer will be held liable for any improperly paid benefits and a penalty will be assessed.

Responsed is Required When the Worker:
  • Was fired or let go for reason other than lack of work;
  • Voluntarily quits, voluntarily retired, or separates due to a health reason;
  • Received or will receive payments at separation time or related to separation;
  • Is on family leave or was hired to cover for an worker on family leave;
  • Still works part-time;
  • Will not return to work on the date specified;
  • Is receiving a monthly pension paid by the employer;
  • The individual is currently working for an Educational Institution and the “Effective date” noted on the form falls within a week of closure;
  • Employers has reason to believe the individual should not be filing for benefits; or
  • Was not the Employer’s employee or worked for someone else subsequently.

How to Complete the Form

Section A

This section must be completed on all forms that are returned to us. Start and End dates of employment help us to gauge a claimant’s experience in this position, which can be relevant in a separation determination. It also helps with allocating the separation pay when applicable.

On occasion we do find employers who report all wages paid to date as “Wages in Lieu of Notice.”

“Wages in Lieu of Notice” is a payment made by an employer to the worker, to compensate him or her for lost wages when no advance notice of a separation was provided.

Hours Worked

To determine the amount of separation pay, we use the formula: hours per day worked x the number of days per week.

When separation pay has been paid, we must allocate it based on the customary work schedule, not just the total hours usually worked per week.

Pay Rate is also needed for allocation of separation pay and determination of wages earned during any week claimed. Additionally, pay rate helps determine suitability of the work. Occupation is needed for suitable work as well as simply having a better understanding of what a person’s job duties were in order to more accurately determine eligibility due to an adverse separation. Location is intended to reflect the location where work was performed and is needed to determine commuting distance for suitable work. Separation reason is vital on all claims. Most circumstances will match one of the choices on the form. If the “Other” box is marked a narrative is required. Please do not use “Other” if the separation is due to a “reorganization”, “downsizing”, “position elimination”, as each of these is technically a lack of work separation.

If the worker is “Still working Part-time or Hours Reduced,” the employer must complete section E to enable us to determine the cause of the part-time status, evaluate the worker’s availability, and potentially relieve the employer’s account of liability if appropriate.

Section B

Payment information is only necessary if the claimant has received:

  • Vacation pay,
  • Wages in lieu of notice,
  • Severance pay
  • Sick pay, or
  • Is currently receiving a pension from the employer.

When these payments have, or will be, paid following the separation, the employer must report the gross dollar amount of each type of payment as well as the number of hours/weeks/etc that was, or will be, paid following the separation.

Combined Time Off (CTO) or Earned Time Off (ETO) should be reported as vacation pay.

*Holiday pay is not disqualifying under Vermont Law.

Section C

Discharge: If the employer indicated in Section A that the separation was due to a discharge, a specific statement regarding the cause of separation is required.

Vague statements such as “Job Performance” will require us to do follow up contacts as we need to know the exact circumstances or failures in performance that lead to discharge.

If supporting documentation exists, please provide it up front. Supporting documentation should include:

  • Copies of written warnings,
  • Policies the claimant is accused of violating,
  • Attendance records as appropriate and
  • Anything else the employer feels would support their decision to terminate employment.

If the employer prefers not to provide information due to what it believes is in its best interest, please simply write, “Employer declines to provide specifics.”

However, if the employer does not meet their burden in showing discharge was for misconduct, benefits will be awarded and the employer’s experience record will likely be impacted by the charges in the future.

Further information about dismissing an employee for misconduct (link to dismissing an employee for misconduct) is available.

Section D

Quit: If the employer indicated in Section A the claimant quit or resigned, the employer must provide whatever information he or she has available. If the worker stated his or her reason for leaving was personal, indicate that.

If leaving was a choice to resign or be discharged, Vermont considers this to be a discharge circumstance and would ask that the employer complete Section C.

Section E

Still working part-time or hours reduced: Under Vermont Law, the Department can evaluate the potential of charge relief for employers who have part-time employees who are filing for benefits.

Section E helps us to understand what the hiring agreement was, if there has been any change in that agreement, and if there has been a change, what caused it.

We also use this information to determine if availability issues need to be explored or if the employer would be entitled to relief of benefit charges. Completing all questions asked with specific information will help us to determine eligibility for the claimant, as well as potential charge relief for the employer.

Any questions about completing the Request for Separation Information should be directed to the Employer’s Assistance line at 1-877-214-3331.

Contact Information

COVID-19 Update: Department of Labor offices are currently closed due to COVID-19. Please contact the Department by phone.

Vermont Department of Labor
5 Green Mountain Drive
P.O. Box 488
Montpelier, 05601-0488
(802) 828-4000

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