Form 115 "Social Security Release Form" - Kentucky

What Is Form 115?

This is a legal form that was released by the Kentucky Department of Workers' Claims - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Kentucky Department of Workers' Claims;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 115 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Workers' Claims.

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Download Form 115 "Social Security Release Form" - Kentucky

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Form 115
Adopted 1/1/97
KENTUCKY
DEPARTMENT OF WORKERS’ CLAIMS
SOCIAL SECURITY RELEASE FORM
I, _________________________________, having filed an Application for
Resolution of Occupational Disease or Hearing Loss Claim for workers’
compensation benefits, do hereby authorize the Social Security Administration to
release or disclose the Department of Workers’ Claims any information in their
possession concerning my benefit or wage earnings.
Signed at _____________________, Kentucky, this the _______ day of
____________________, 20______.
__________________________
Plaintiff’s Signature
__________________________
Social Security Number
_____________________________
Witness Signature
Form 115
Adopted 1/1/97
KENTUCKY
DEPARTMENT OF WORKERS’ CLAIMS
SOCIAL SECURITY RELEASE FORM
I, _________________________________, having filed an Application for
Resolution of Occupational Disease or Hearing Loss Claim for workers’
compensation benefits, do hereby authorize the Social Security Administration to
release or disclose the Department of Workers’ Claims any information in their
possession concerning my benefit or wage earnings.
Signed at _____________________, Kentucky, this the _______ day of
____________________, 20______.
__________________________
Plaintiff’s Signature
__________________________
Social Security Number
_____________________________
Witness Signature