LWC 65W (07/09)
ELIGIBILITY REVIEW
___________________________________ ________________________
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
Date:
Please Print Your Mailing Address: _____________________________________________
Your City, State and Zip Code: _____________________________________________
Your Telephone Number: _____________________________________________
