Fillable Mailing Address: Louisiana Workforce Commission Office of UI

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Mailing Address: Louisiana Workforce Commission Office of UI

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

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Completed 4 January 2021

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