LOUISIANA DEPARTMENT OF LABOR
WEEK CLAIMED
Sunday
Saturday
WEEKLY REQUEST FOR ALLOWANCES BY
Beginning Date
Ending Date
JOB SEEKER IN TRAINING
TRADE ACT OF 1974, AS AMENDED
JOB SEEKER’S NAME (Last, First Middle)
SOCIAL SECURITY NO.
PETITION NO.
MAILING ADDRESS ( Street Address, City, State, ZIP Code)
1. Did you attend all of your scheduled classes for the week being claimed? [ ] YES [ ] NO*
If no explain:
*Provision for Active Attendance and Justifiable Cause apply. Please refer to form LDOL TRA5
“IMPORTANT NOTICE TO
TAA/NAFTA-TAA TRAINEES”
for additional information.
2. Were you employed or in On-the-Job Training during the week being claimed? [ ] YES [ ] NO
If yes, place a check mark by your “Reason for Leaving”:
[ ] Quit or Resigned
[ ] Still Employed/Part-Time
[ ] Laid Off due to a Lack of Work or Reduction in Force
[ ] Fired or Discharged
[ ] On-the-Job Training
Name and Address of Employer
Gross Earnings
$
3. Did you begin receiving workers compensation, social security, a veteran’s administration allowance, or any other pension or
allowance during this week? [ ] YES [ ] NO
If yes, complete the following:
Type ______________
Date Received ______________________
and Gross Monthly Amount $________________
4. Did you receive vacation, severance, or holiday pay during this week? [ ] YES [ ] NO
If yes, complete the following:
Type ______________
Date Received ______________________
and Gross Amount $________________
I HEREBY CERTIFY THAT THESE STATEMENTS ARE TRUE AND CORRECT, AND FOR THE ABOVE WEEK, I
AM NOT CLAIMING OR RECEIVING FROM ANOTHER STATE ANY BENEFITS RELATED TO MY
UNEMPLOYMENT. I UNDERSTAND THAT THE LAW PROVIDES PENALTIES FOR FALSE STATEMENTS.
Signature of Job Seeker
Date
LDOL 858A (R 7/02)
RETURN COMPLETED FORM TO:
TRA PAYMENT UNIT – ROOM 370
POST OFFICE BOX 94094
BATON ROUGE, LA 70804