Separation Notice Form (Page 2 of 3) in pdf

INSTRUCTIONS TO EMPLOYER FOR PREPARATION OF

SEPARATION NOTICE ALLEGING DISQUALIFICATION

We encourage you to submit the form online at

A Separation Notice Alleging Disqualification should be made out in triplicate for each worker who leaves your employ without good

cause connected with his work, is discharged for misconduct connected with his work, or is unemployed because of a labor dispute.

Fax or mail an original to the Administrator, Louisiana Workforce Commission, Post Office Box 91253, Baton Rouge, Louisiana

70821-9253 within 72 hours after employee has been separated from work. Give a duplicate copy to the worker along with the

“Instructions To The Worker”, or if delivery is impossible, mail to his last known address within 72 hours.

Keep a triplicate in your files for reference.

Item 1 Enter here the worker’ s full name as it appears on your records. If it is different from that on the

Social Security card, please indicate in the explanation area.

Enter worker’ s Social Security Number. If it is known to you that he has more than one number,

please indicate in the explanation area.

Enter the date the worker was separated from your employ.

Enter the date the worker was hired.

Enter the date the worker last worked.

Item 2 Check the reason for separation and explain in detail in space provided.

Voluntary Leaving: give the detailed reason for leaving so that it can be determined whether

or not a disqualification for leaving without good cause attributable to a substantial change

with the employment should be assessed.

Discharge (Fired): give the detailed reason for discharge so that the information can

be used in determining whether or not a disqualification should be assessed for misconduct

connected with the work.

Lack of Work (RIF): No other work available.

Leave of Absence: give complete details as to the reason for the leave and the time period

involved.

Not Physically Able to Work: give all details known to you relative to the worker’ s illness or

injury.

School Employee: give complete information relative to reason for the separation and

whether or not the worker had a contract or a reasonable assurance of returning.

Refused Other Suitable Work: give detailed information relative to the new work offered,

such as, salary, hours, job conditions, location, etc.

Labor Dispute/Union Strike: give details of labor dispute so that the information can be used in

determining whether or not the worker is disqualified for benefits due to participation in the

dispute.

Retirement: give the detailed reason for retirement, whether voluntary or compulsory, exact

amount of pension before deductions, and whether company contributed, employee

contributed or a combination of employer/employee contributions.

Work Part-Time: if the employee is currently working part-time, or his/her hours have been

reduced from full-time to part-time work, please provided an explanation and include the

number of hours worked each week. The hourly rate of pay should also be included.

Items 3 and 4 Complete as indicated on the form. Report gross total payments.

This notice should be filled out and signed by an officer or employee authorized to assume responsibility for the information and

his/her title or position. This notice should be dated as of the date it is handed or mailed to the worker and faxed to 225-346-6068 or

mailed to the Administrator, Louisiana Workforce Commission, Post Office Box 91253, Baton Rouge, Louisiana 70821-9253.

Separation Notice Form Page 2

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