HTML Preview Job Separation Notice page number 1.
Separation Notice
77 Rev 0/08
000770801
*000770801*
1. Applicant Information
Last
Name:
First Name:
SSN:
M M D D Y Y
Date of
Separation:
M M D D Y Y
Date Hired:
M M D D Y Y
Date Last
Worked:
Please provide detailed explanation for the items checked below. Should this individual file a claim for unemployment insurance
benefits, complete facts will enable this agency to make an equitable decision.
2. Reason for Separation
Voluntary Leaving (Quit)
Discharged (Fired)
Lack of Work (Reduction in Force)
Leave of Absence
Not Physically Able to Work
School Employee Contract
Refused Other Suitable Work
Labor Dispute/Union Strike
Retirement
Work Part Time
3. Vacation, Severance, Dismissal, Bonus, Holiday Pay Information
Vacation/Accrued
Leave – Not PTO
# Hrs
Severance/
Dismissal
$
Bonus
$
$
I certify that the worker whose name and social security number appear above has been separated from work and that the above
information is true and correct. I further certify that the individual has been handed or mailed a copy of this notice.
Printed Name
Phone Number
Signature
Title
FILL OUT IN TRIPLICATE. Mail original within 72 hours after separation.
Give a copy of this form and a copy of the “Instructions to the Worker” to the
employee within 72 hours, and retain a copy for your files.
File online at: http://www.laworks.net
Employer Name
Failure to submit this notice within the specified time limits may forfeit your right to appeal. It must be submitted within 72
hours after the worker’s separation from employ.
Employer Account No.
Explain the reason for separation:
4. Pension
Holiday Pay
Louisiana Workforce Commission
Adjudication Support Unit
P. O. Box 91253
Baton Rouge, LA 70821-9253
Fax (225) 346-6068
$
Wages in Lieu of
Notice
Hourly Rate of Pay
$
$
Street Address
City
State
Zip
Telephone Number
Fax Number
Hrs Worked per Week
# Hrs
# Hrs
# Hrs
# Hrs
$
__ Monthly __ Lump Sum
If lump sum, what would the monthly amount
be if that option had been chosen?
MAIL or FAX TO –
Louisiana Workforce Commission
Adjudication Support Unit
Post Office Box 91253
Baton Rouge, LA, 70821-9253
Fax (225) 346-6068
$