1/16/2067 12:51 anaesazz16 CORRECTIONAL MEDICAL, PAGE 84/86 State of Georgia Department 3 Labor SEPARATION NOTICE 1. Empteyse’s Name _C2aila Babalon 2. State any other name(s) under which employee worked. 3. Petiod of Lest Employment: From 4/18/2007 ‘. HEASON FOR SEPARATION:~ (, & LACK OF WORK T] ~ Bsloceg bp $e Sea ae ta 2 S.5.No, te 10 4Ip007 meyoe Fallacy, Co |te | Bes ay 2 st tr mara ct ot wc, icy dae ToS eek eS wre S Employae mecsived payment ler (Severance Pay, Separation Pay, Wagae-in ou of (0 NOT include vacation pay or eared wages) — inthe sovount of § RR aa —— Pato above paymont(a) wasiwil bo Issued 19 employee. 5. Dié thie employes oa atleast $3,000.00 In your employ? YES RaRore"* Correctional Medical Associates iI 3379 Peachinve Road NE Addrase_ Suite 320, instar RET sie GA) 30326 ——_ ZIP Code 760-0298 a) | NOTICE TO EMPLOYER {Al the time of separation, you are raqured by te Employment Security Law, OCGA Section 34-8-180(c}, te prodde tre employee wih this document, propery eraculed’ ging. the fBesons for sepamaton. I you subsequndly recone & Meuse {or ‘the came information on 3 DOL-V189FF, vou may ater a Copy ofthis form {OOL-800) as a part of your reupanee, cy Atlante Employer's ‘leper to, 404 NOTICE TO THE GEORGIA DEPARTMENT OF LABOR FOR UNEMPLOYMENT INSURANCE BENEFITS. °% Of connibutios pald by employer NOTICE TO EMPLOYEE NOTES UON 34-5-180(c) OF THE EMPLOYMENT SECURITY LAW REOUI NO 1) HNO, how @nuch? § = Average Why Wag Gt D.0.L. account Numtine _505211-03 (Number shown on Emoloyst's Gurr Tax and Wage Ropar: FomDOL-4) |LOSRTIPY mat i86 above wdfkar has beon Separated from work ‘and the iformation fumishet herson fs true and correct. This ‘report hn sen handod to oxmalies to the worker Oyen. rae FONG Ses SRE EE —— oF authoriced agont farms ampioyer Chiet Medical Officar TRF Sse Signy —————— sortv2007 aiaase is Emproyes IRES THAT YOU TAKE THIS FIELD SERVICE OFFICE IF YOU FILE ACCLAIM DOL-800 (F-5/89)18/16/2887 12:51 anqasa2z1e CORRECTIONAL MEDICAL PAGE A3/@5 [ CORRECTIONAL MEDICAL ASSOCIATES | PERSONNEL ACTION FORM Complove th for for ali Pesomvel Actions Ginew Hire Desire Memninaion Ovecaimn Lr Usoay \Crevee _D Stan Change _D Seheduie Change H Personal Date Ghonpe ong twa Hob anny meters [- Tost Name ‘First Nome ‘Middle Initia | ‘Social Security fective Date Bahalola | Cecilia | lala —— Wie. eee 7 lly sen a a — hema Ort Ort OPN M1 ton “Sai Wopes O) Hourly 1 Soieried ‘Work Schadile Dis Dem 136 Geobend * " ae Op am 830 pm arteer ; SOPMPLETE IMIS SECON FOR STATUS, SALARY AND/OR SCHEDULE CHANGES Selon. Or Shee Change =] aaa Date isda Deter Bae Bae 1 Fon” i Fem i fam COMPLETE THIS SECTION FOR ALL LEAVE: VACATION Te TR Date [Tata ot Hors | reavenes ~ P70-L0.8-EDUCATIONAL.- MILITARY ~ FAMILY "Tb maidvol bas corneas ‘Signotwre oFemseyae work iy plows ‘Dsrening to werk i ‘COMPLETE THIS SECTION FOR EMPLOYMENT SEPARATION Yolumerny Reeignation _ Dischoroed we Other. tox Doy Worked at i]O7) EMPLOYEE REMARKS AND EXRLANATIONS ADMINSTATTVERBUADKS AN BANDON inno presen ce Capone _L. ‘Sionotore 7 Dow Doe Dinners Soe Dave