This government document is issued by Department of Labor for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://dol.georgia.gov/documents/claimant-wage-and-liability-inquiry-dol-2349c/download&sa=U&ved=2ahUKEwijt-a4kJeHAxWF3AIHHbLmD144MhAWegQIBRAB&usg=AOvVaw3U9P1aWcgWg386chnYI6r_&fexp=72519171,72519168