Fillable Printable Job Seekers Allowance Form - Louisiana

Job Seekers Allowance Form - Louisiana

WEEK CLAIMED

LOUISIANA WORKFORCE COMMISSION

WEEKLY REQUEST FOR ALLOWANCES BY

JOB SEEKER IN TRAINING

TRADE ACT, AS AM E NDED

Sunday

Beginning Date

Saturday

Ending Date

JOB SEEKER’S NAME (Last, First Middle)

SOCIAL SECURITY NO.

PETITION NO.

MAILING ADDRESS ( Street Address, City, State, ZIP Code)

1. Did you attend all of your scheduled classes for the week being claimed? [ ] YES [ ] NO*

If no explain:

*Provisi o n for Active At tendance and Jus ti fiabl e C ause apply. Please refer to form LDOL TRA5 “IMPORTANT NOTICE TO

TAA/NAFTA-TAA TRAINEES” for additional information.

2. Were you employed or in On-the-Job Training during the week being claimed? [ ] YES [ ] NO

I f yes, place a check mark by your “Reason for Lea ving”:

[ ] Quit or Resigned [ ] Still Employed/Part-Time [ ] Laid Off due to a Lack of Work or Reduction in Force

[ ] Fired or Discharged [ ] On-the-Job Training

Name and Address of Employer

Gross Earnings

3. Did you begin receiving workers com pensation, a veteran’s adm inistration allowance, or any other pension or

allowance during

this week? [ ] YES [ ] NO

If yes, com plete the follo w ing:

T ype ______________ Date Received ______________________ and Gross Monthl y Amount $________________

4. Did you receive vacation, severance, or holiday pay during this week? [ ] YES [ ] NO

If yes, complete the following:

Type ______________ Date Received ______________________ and Gross Amount $________________

I HEREBY CERTIFY THAT THESE STATEMENTS ARE TRUE AND CORRECT, AND FOR THE ABOVE WEEK, I

AM NOT CLAIMING OR RECEIVING FROM ANOTHER STATE ANY BENEFITS RELATED TO MY

UNEMPLOYMENT. I UNDERSTAND THAT THE LAW PROVIDES PENALTIES FOR FALSE STATEMENTS.

Signature of Job Seeker

Date

LWC 858A (R 7/08)

RETURN COMPLETED FORM TO:

TRA PAYMENT UNIT – ROOM 370

POST OFFICE BOX 94094

BATON ROUGE, LA 70804