Form Ldol-Es 77 - Separation Notice Alleging Disqualification
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1
2FORM LDOL-ES 77 (R 5-98)
SEPARATION NOTICE ALLEGING DISQUALIFICATION
1. NAME
2. SS NO.
4. DATE
5. DATE LAST
3. DATE OF SEPARATION
HIRED
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
.
7.
VACATION/SEVERANCE/DISMISSAL/BONUS/HOLIDAY PAY
6. REASON FOR LEAVING: (Please Check)
INFORMATION. The employee received or will receive:
( ) Vacation
G
$_____________
week(s) _____________
01
Voluntary Leaving (Quit)
( ) Severance/Dismissal
$_____________
week(s) _____________
( ) Bonus
G
$_____________
week pd. ____________
02
Discharge, (Fired)
( ) Holiday Pay
$_____________
week(s) _____________
Lump sum ( ) vacation ( ) accrued leave
G
03
( ) severance/dismissal pay ( ) bonus
Lack of Work (R.I.F.)
( ) holiday pay ( ) other remuneration
covers a period of ________ week(s)
G
04
Leave of Absence
G
05
Not Physically Able to Work
G
06
School Employee Contract
G
07
Refused Other Suitable Work
G
08
Labor Dispute
G
09
Retirement, Pension
G
10
Other (Please Explain)
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
Employer Name
.
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