Mailing Address: Louisiana Workforce Commission
                                                                                                                    Office of UI Administration
                                                             Adjustments Unit
 REQUEST FOR RECERTIFICATION                                 P.O. Box 94100
 (Proof of Credit - 940C)                                                            Baton Rouge, LA  70804-9100
This form is semi-interactive.  You can complete             Phone:1-866-783-5567  Fax: (225) 346-6071
 the request online but must mail or fax it.

 State ID #                                      Federal ID#

 Year Requested

 Name of Business

 Account is  active (     )         Account is inactive(    )

 Requested By                                                Title
 Signature
 Phone Number
 Fax Number
 Date
 Comments

 This section for agency use only.

 State ID #                          

 Year Requested

 Rate

 Taxable Wages

 Contributions Paid After January 31st

 Contributions Paid Before February 1st

 Processed By

 Date Entered

Last Rev.- (06/09)