Form B-652 "Claimant's Waiver and Authorization to Release Information" - Colorado

Form B-652 or the "Form B-652 "claimant's Waiver And Authorization To Release Information" - Colorado" is a form issued by the Colorado Department of Labor and Employment.

Download a PDF version of the Form B-652 down below or find it on the Colorado Department of Labor and Employment Forms website.

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Download Form B-652 "Claimant's Waiver and Authorization to Release Information" - Colorado

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Colorado Department of Labor and Employment, Unemployment Insurance, P. O. Box 400, Denver, CO 80201-0400
303-318-9000 (Denver-metro area) or 1-800-388-5515 (outside Denver-metro area)
CLAIMANT’S WAIVER AND AUTHORIZATION TO RELEASE INFORMATION
Complete this form if you intend to waive your confidentiality rights under § 8-72-107(1), C.R.S. and want the Unemployment
Insurance (UI) Division to release information about you to a third party or group. You must state what information you want
released. You must sign and date this form. This form must be notarized. We will not honor your request to release information
unless all necessary fields are completed. We will not honor blanket requests for “all records” or “complete files.”
The UI Division may release information or records to:
Name
Title
Address
Please state the specific purpose you want the information released. __________________________________________________
_________________________________________________________________________________________________________
The information to be provided is for the period from
_____________________ to
______________________________.
Check the box(es) that describes the type(s) of information you want us to release.
Claimant Benefit-Payment History
Copies of any/all documents I provided to the UI Division
Copies of decisions mailed to me by the UI Division
Other (Please describe in detail below)
By signing this form, you agree and understand that the information released will only be used for the above stated purpose and that
the release of this information provides a service or benefit to you.
Sign this form in the presence of a Notary Public.
Your Name
Your Social Security Number
Notary
Signature
Date
Subscribed and sworn to before me in the County of ______________________________, State of ___________________________,
this __________________________________ day of __________________________________, 20_________________________.
My Commission Expires
Notary Public
Office Use Only
Records Mailed
Mailed By
Date Mailed
CLEAR FORM
SAVE FORM
B-652 (R 12/2015)
Colorado Department of Labor and Employment, Unemployment Insurance, P. O. Box 400, Denver, CO 80201-0400
303-318-9000 (Denver-metro area) or 1-800-388-5515 (outside Denver-metro area)
CLAIMANT’S WAIVER AND AUTHORIZATION TO RELEASE INFORMATION
Complete this form if you intend to waive your confidentiality rights under § 8-72-107(1), C.R.S. and want the Unemployment
Insurance (UI) Division to release information about you to a third party or group. You must state what information you want
released. You must sign and date this form. This form must be notarized. We will not honor your request to release information
unless all necessary fields are completed. We will not honor blanket requests for “all records” or “complete files.”
The UI Division may release information or records to:
Name
Title
Address
Please state the specific purpose you want the information released. __________________________________________________
_________________________________________________________________________________________________________
The information to be provided is for the period from
_____________________ to
______________________________.
Check the box(es) that describes the type(s) of information you want us to release.
Claimant Benefit-Payment History
Copies of any/all documents I provided to the UI Division
Copies of decisions mailed to me by the UI Division
Other (Please describe in detail below)
By signing this form, you agree and understand that the information released will only be used for the above stated purpose and that
the release of this information provides a service or benefit to you.
Sign this form in the presence of a Notary Public.
Your Name
Your Social Security Number
Notary
Signature
Date
Subscribed and sworn to before me in the County of ______________________________, State of ___________________________,
this __________________________________ day of __________________________________, 20_________________________.
My Commission Expires
Notary Public
Office Use Only
Records Mailed
Mailed By
Date Mailed
CLEAR FORM
SAVE FORM
B-652 (R 12/2015)
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