Louisiana Workforce Commission
Adjudication Support Unit                                  Separation Notice
P. O. Box 91253
Baton Rouge, LA 70821-9253
Fax (225) 346-6068

1. Applicant Information
First Name:                                                             Last 
                                                                       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
               Voluntary Leaving (Quit)                    Hourly Rate of Pay    $                                     Hrs Worked per Week

               Discharged (Fired)                           Vacation/Accrued       $                                             # Hrs
                                                            Leave – Not PTO
               Lack of Work (Reduction in Force)
                                                            Severance/
               Leave of Absence                             Dismissal              $                                             # Hrs

               Not Physically Able to Work                  Bonus                  $                                             # Hrs
               School Employee Contract
                                                            Holiday Pay            $                                             # Hrs
               Refused Other Suitable Work
                                                            Wages in Lieu of 
               Labor Dispute/Union Strike                   Notice                 $                                             # Hrs

               Retirement                                  4. Pension
               Work Part Time                               __ Monthly  __ Lump Sum                                  $

Explain the reason for separation:                         If lump sum, what would the monthly amount                 $
                                                           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 Name                                                                        Employer Account No.

                              Street Address                                                                    City             State     Zip

      Telephone Number                                                 Fax Number

Signature                                                                          Printed Name

Title                                                                              Phone Number
FILL OUT IN TRIPLICATE. Mail original within 72 hours after separation.            MAIL or FAX TO –
                                                                                   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:   http://www.laworks.net                                           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

                  *000770801*
                  000770801

                  INSTRUCTIONS TO EMPLOYER FOR PREPARATION OF
                  SEPARATION NOTICE ALLEGING DISQUALIFICATION

                        We encourage you to submit the form online at www.laworks.net.

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.

                          INSTRUCTIONS TO THE WORKER

Having become unemployed, you should go to a Business and Career Solutions Center most 
convenient to you and register for work. If you intend to file a claim for benefits, you may do so at the same 
time or file a claim via the Call Center at 1-866-783-5567. Under the Louisiana Employment Security Law, 
you may be disqualified for benefits, if it is determined that:

                          You left your work without good cause attributable to a substantial
                          change with your employment, or

                          You were discharged for misconduct connected with your work, or

                          You failed to accept suitable work when offered or to apply for available
                          suitable work, when so directed by the Administrator or the employment
                          office, or

                          You were taking part in a labor dispute in the establishment in which you
                          were employed, or you were seeking unemployment compensation benefits
                          under any other State or Federal Law.

It is important for you to register for work immediately even though you may be temporarily
disqualified for benefits.

In deciding whether you are disqualified, the Louisiana Workforce Commission will consider the
statements made by your employer on Form LWC 77, Separation Notice, concerning the reason for your
separation and the statements you make when you file your claim for benefits. If you do not agree with the 
reasons for leaving your job as given on the Form LWC 77, Separation Notice, provide a detailed statement 
on your Unemployment Insurance Application.

NOTE: It is not necessary to EMPLOY any one to help you collect benefits. Representatives of
the Louisiana Workforce Commission will advise you and help you with your claim.

REGISTER at once at the most convenient Business and Career Solutions Center or via the Call 
Center at 1-866-783-5567.