LWC 65W (07/09)
___________________________________ ________________________
Print Your Name Your Social Security Number
To maintain your eligibility requirements for unemployment insurance benefits, a review of your
work search record is required. When instructed, you must complete the items below and fax this
form to (225) 346-6068 or mail this form to the Louisiana Workforce Commission, Adjudication
Support Unit, P. O. Box 91253, Baton Rouge, LA 70821-1253. This form is semi-interactive and
may be filled out online, then printed and mailed. Failure to return this form timely could result
in your being disqualified for benefits.
Answer the following questions:
1. Are you attending any school or training program now? If so, list the name
of the school and the course of study:
2. Is there any reason why you cannot look for a job or accept one now?
(Such as a lack of transportation, a physical disability, pregnancy, childcare
problems, etc.)
3. Are you working full-time, part-time, in self-employment, on a
commission basis, in operating a farm or as an elected official, etc?
4. Do you have a definite prospect of employment? (In other words, have
you been given a date to begin work by a specific employer?) If so, list the
name of the employer and the date you will begin working.
Yes No
Yes No
Yes No
Yes No
Record of work search or union contacts:
List one job contact you have made in each of the last three (3) weeks:
Date Name of Company or Name of Union Officer Contacted
Certification: I have answered these questions and provided a record of my work search
contacts to obtain unemployment benefits. I know that this information is
subject to verification and that the law provides penalties for false statements.
Your Signature: Today’s
Please Print Your Mailing Address: _____________________________________________
Your City, State and Zip Code: _____________________________________________
Your Telephone Number: _____________________________________________