FORM LDOL 77 (R 1-00)
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 ORIGINAL TO - Administrator, Louisiana Department of Labor, Post Office Box
94094, Baton Rouge, LA, 70804-9094 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.