Form Lwc 77 - Separation Notice Alleging Disqualification

FORM LWC 77 (R 06-09)

SEPARATION NOTICE ALLEGING DISQUALIFICATION

1. NAME ______________________________________ 2. SS NO. __________________________________________

3. DATE OF SEPARATION ____________ 4. DATE HIRED____________ 5. DATE LAST WORKED ____________

PLEASE PROVIDE DETAILED EXPLANATION for item checked below. Should this individual file a claim for

unemployment insurance benefits, complete facts will enable this agency to make an equitable decision.

6. REASON FOR LEAVING:

7. VACATION, SEVERANCE, DISMISSAL, BONUS,

HOLIDAY PAY INFORMATION

01 ( ) Voluntary Leaving (Quit)

The employee received or will receive:

02 ( ) Discharge (Fired)

( ) Vacation

$ __________ week(s) ______

03 ( ) Lack of Work (R.I.F.)

( ) Severance/Dismissal $ __________ week(s) ______

04 ( ) Leave of Absence

( ) Bonus

$ __________ week(s) ______

05 ( ) Not Physically Able to Work

( ) Holiday Pay

$ __________ week(s) ______

06 ( ) School Employee Contract

07 ( ) Refused Other Suitable Work

LUMP SUM

( ) Vacation ( ) Accrued Leave

08 ( ) Labor Dispute

( ) Severance/Dismissal Pay ( ) Bonus

09 ( ) Retirement, Pension

( ) Holiday Pay ( ) Other Remuneration

10 ( ) Other (Please Explain)

covers a period of __________week(s).

EXPLANATION:

_______________________________________________________________________________________________________

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.

8. ____________________________________ 9. _______________________

10. ___________________________

Employer Name

Phone - Area Code & No.

Employer Acct. No.

11. ___________________________________________________________________12. ___________________________

Address

Street/Box

City

State

Zip Code

13. ___________________________________ 14. ___________________________ 15. __________________________

Signature

Title

Date

_______________________________________________________________________________________________________

FILL OUT IN TRIPLICATE. MAIL OR FAX (225) 346-6068 ORIGINAL TO - Administrator, Louisiana Workforce

Commission , Post Office Box 91253, Baton Rouge, LA, 70821-9253 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.

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.

Form Lwc 77 - Separation Notice Alleging Disqualification - 2009

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