Separation Notice Form

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Separation Notice
Louisiana Workforce Commission
Adjudication Support Unit
P. O. Box 91253
Baton Rouge, LA 70821-9253
Fax (225) 346-6068
1. Applicant Information
Last
First Name:
Name:
SSN:
Date of
Date Last
Separation:
Date Hired:
Worked:
M
M
D
D
Y
Y
M
M
D
D
Y
Y
M
M
D
D
Y
Y
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
3. Vacation, Severance, Dismissal, Bonus, Holiday Pay Information
Hourly Rate of Pay
$
Hrs Worked per Week
Voluntary Leaving (Quit)
Discharged (Fired)
Vacation/Accrued
# Hrs
$
Leave – Not PTO
Lack of Work (Reduction in Force)
Severance/
$
# Hrs
Leave of Absence
Dismissal
Not Physically Able to Work
Bonus
$
# Hrs
School Employee Contract
Holiday Pay
# Hrs
$
Refused Other Suitable Work
Wages in Lieu of
$
# Hrs
Labor Dispute/Union Strike
Notice
Retirement
4. Pension
Work Part Time
$
__ Monthly __ Lump Sum
If lump sum, what would the monthly amount
Explain the reason for separation:
$
be if that option had been chosen?
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.
Employer Account No.
Employer Name
State
Zip
Street Address
City
Telephone Number
Fax Number
Signature
Printed Name
Title
Phone Number
MAIL or FAX TO –
FILL OUT IN TRIPLICATE. Mail original within 72 hours after separation.
Louisiana Workforce Commission
Give a copy of this form and a copy of the “Instructions to the Worker” to the
Adjudication Support Unit
employee within 72 hours, and retain a copy for your files.
Post Office Box 91253
Baton Rouge, LA, 70821-9253
File online at:
Fax (225) 346-6068
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.
77 Rev 0/08
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000770801

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