Ldol 77 Form – Fill Out and Use This PDF

Form LDOL 77 Separation Notice Alleging Disqualification

Get the Paper Form

Get the Instructions

Thank you for accessing this Louisiana Department of Labor Interactive Form. The following is a brief overview of how the form functions.

Complete all required entries according to instructions preceding each item. After the last entry, click "SUBMIT." If errors are detected, the first page of the form will return with further instructions printed in red. Scroll down and correct all errors, and then click "SUBMIT" again. When the form has been completed successfully, a "SUBMISSION ACCEPTED" page will return. Print this 'SUBMISSION ACCEPTED" page for your records.

A Separation Notice Alleging Disqualification should be completed for each worker who leaves your employ without good cause connected with his work, is discharged

for misconduct connected with the employment, or is unemployed because of a labor dispute.

Submit within 72 hours after each employee has been separated from work.

You may download and print out a blank copy of this form from the links at the bottom of this page.

Give a copy to the worker along with Workers' Claim Information and

Form LDOL 87 or, if delivery is impossible, mail to his last known address within 72 hours.

Keep a copy in your files for reference.

Name

Enter the worker's full name as it appears on your records. If it is different from that on the Social Security Card, put the recorded name here and

report both names in the explanation box below.

Social Security Number

Enter the worker's Social Security Number.

If it is known to you that the worker

has more than one number,

record the first number here and

report all numbers in the explanation box below.

Dates

Enter the date the worker was separated from your employ,

the date the worker was hired,

and the date the worker last worked.

Enter Dates in this format: mm/dd/ccyy.

Date Separated: / /

Date Hired: / /

Date Last Worked: / /

		Reason for leaving:	Check one reason for leaving and explain in
			the Explanation box below.
	01	Voluntary Leaving (Quit)	01 - Voluntary Leaving: give the reason for leaving so
	02	Discharge (Fired)	that it can be determined whether or not a
			disqualification for leaving without good cause
	03	Lack of Work (R.I.F.)	attributable to a substantial change with the
	04	Leave of Absence	employment should be assessed.
	05	Not Physically Able to Work02- Discharge, Misconduct: give the reason for
	06	School Employee Contract	discharge so that the information can be used in
			determining whether or not a disqualification should be
	07	Refused Other Suitable	assessed for misconduct connected with the work.
	Work		03- Lack of Work (RIF)
	08	Labor Dispute
	09	Retirement/Pension	04- Leave of Absence: give details as to the reason for
			the leave and the time period involved.
	10	Other	05- Not Physically Able to Work: give all known
	Vacation/Severance/Dismissal/		details relative to the worker's illness or injury.
	Bonus/Holiday Pay Information

	Please do not use commas	06- School/Employee Contract: give information
		relative to reason for the separation and whether or not
	when entering dollar amounts.

If the number of weeks is less than one the worker had a contract or a reasonable assurance of week, enter one (1) in the weeks block and returning.

provide the number of days in the

explanation block.

Phone: ( ) -

Enter the employer's name and address in the designated fields.

Employer Name:

Louisiana Employer Account Number:

Please enter the first six digits of your account number.

Street Address:

City:

State:

LA - LOUISIANA

ZIP Code: