Form MODES-4354-3 Authorization for Release of Confidential Information - Missouri

Form MODES-4354-3 is a Missouri Department of Labor and Industrial Relations form also known as the "Authorization For Release Of Confidential Information". The latest edition of the form was released in September 1, 2011 and is available for digital filing.

Download an up-to-date Form MODES-4354-3 in PDF-format down below or look it up on the Missouri Department of Labor and Industrial Relations Forms website.

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
AUTHORIZATION FOR RELEASE OF
CONFIDENTIAL INFORMATION
I hereby authorize the Missouri Department of Labor and Industrial Relations, Division of Employment Security, to release
confidential information to ____________________________________________________ for the purpose of making demand
for payment on letter of credit number __________________________________________ as long as the obligation remains in
force and effect. Release of this information to the named banking institution does not give the banking institution authority to
request information other than information concerning the delinquent periods for which a demand for payment is being made. I
also release the Missouri Department of Labor and Industrial Relations, Division of Employment Security, and Division
personnel from any and all liability under section 288.250, RSMo, resulting from the release and disclosure of confidential
information to this banking institution.
In witness whereof I, (We) have duly executed the foregoing this ___________________________________ day of
___________________________, 20_______.
______________________________________________________________________________________________________
Lessor Employing Unit
Typed and Printed
______________________________________________________________________________________________________
Unemployment Contribution Account Number
______________________________________________________________________________________________________
Owner/Officer
Signature
______________________________________________________________________________________________________
Name and Title
Typed and Printed
Before me personally appeared _____________________________________________________ who acknowledges that
s/he signed the foregoing as his/her free act and deed.
I have hereunto set my hand and affixed my official seal at my office in this ___________________________ day of
____________________, 20_______.
My term expires _____________________________
______________________________________________________
Notary Public
MODES-4354-3 (09-11) AI
Cont.
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
AUTHORIZATION FOR RELEASE OF
CONFIDENTIAL INFORMATION
I hereby authorize the Missouri Department of Labor and Industrial Relations, Division of Employment Security, to release
confidential information to ____________________________________________________ for the purpose of making demand
for payment on letter of credit number __________________________________________ as long as the obligation remains in
force and effect. Release of this information to the named banking institution does not give the banking institution authority to
request information other than information concerning the delinquent periods for which a demand for payment is being made. I
also release the Missouri Department of Labor and Industrial Relations, Division of Employment Security, and Division
personnel from any and all liability under section 288.250, RSMo, resulting from the release and disclosure of confidential
information to this banking institution.
In witness whereof I, (We) have duly executed the foregoing this ___________________________________ day of
___________________________, 20_______.
______________________________________________________________________________________________________
Lessor Employing Unit
Typed and Printed
______________________________________________________________________________________________________
Unemployment Contribution Account Number
______________________________________________________________________________________________________
Owner/Officer
Signature
______________________________________________________________________________________________________
Name and Title
Typed and Printed
Before me personally appeared _____________________________________________________ who acknowledges that
s/he signed the foregoing as his/her free act and deed.
I have hereunto set my hand and affixed my official seal at my office in this ___________________________ day of
____________________, 20_______.
My term expires _____________________________
______________________________________________________
Notary Public
MODES-4354-3 (09-11) AI
Cont.

Download Form MODES-4354-3 Authorization for Release of Confidential Information - Missouri

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