"Authorization to Release Records - Employer" - Washington

Authorization to Release Records - Employer is a legal document that was released by the Washington State Employment Security Department - a government authority operating within Washington.

Form Details:

  • Released on August 1, 2019;
  • The latest edition currently provided by the Washington State Employment Security Department;
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Authorization to Release Records - Employer
A. AUTHORIZATION TO DISCLOSE CONFIDENTIAL UNEMPLOYMENT INSURANCE PROGRAM RECORDS:
NAME OF EMPLOYER
IDENTIFYING NUMBER (ESD ACCOUNT#, UBI, FEIN – NEEDED TO PROCESS):
B. DISCLOSE AND SEND RECORDS TO:
NAME
LAST
FIRST
TITLE (IF APPLICABLE)
ORGANIZATION OR BUSINESS NAME (IF APPLICABLE)
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
FAX NUMBER
EMAIL ADDRESS
REQUIRED IF RELEASING TO A THIRD PARTY
STATE PURPOSE OF DISCLOSURE (
):
C. RECORDS AUTHORIZED TO RELEASE:
I authorize the following confidential employer unemployment insurance program information and records to be
released to the third party entity identified in Section B. I understand State governmental files will be accessed
to provide the requested information/records. The identified third party entity is only authorized to use the
requested information/records for the stated purpose. State records being released to include time period:
D. SIGN REQUEST FOR RECORDS
By signing below I declare under the penalty of perjury under the laws of the State of Washington that I am the
business owner or an authorize representative of the employer whose confidential unemployment insurance
program information and records is being requested.
PRINT NAME, TITLE AND SIGNATURE OF OWNER OR AUTHORIZED REPRESENTATIVE:
DATE REQUESTED:
X
MAILED OR FAXED IN REQUESTS WILL BE RESPONDED TO WITHIN 5 TO 10 BUSINESS DAYS. SEND REQUEST TO:
ESD Records Disclosure Unit P.O. Box 9046 Olympia WA 98507-9046
Fax: 1-866-610-9225
Any questions contact the ESD Records Disclosure Unit at 1-844-766-8930
Rev. 08/2019
Authorization to Release Records - Employer
A. AUTHORIZATION TO DISCLOSE CONFIDENTIAL UNEMPLOYMENT INSURANCE PROGRAM RECORDS:
NAME OF EMPLOYER
IDENTIFYING NUMBER (ESD ACCOUNT#, UBI, FEIN – NEEDED TO PROCESS):
B. DISCLOSE AND SEND RECORDS TO:
NAME
LAST
FIRST
TITLE (IF APPLICABLE)
ORGANIZATION OR BUSINESS NAME (IF APPLICABLE)
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
FAX NUMBER
EMAIL ADDRESS
REQUIRED IF RELEASING TO A THIRD PARTY
STATE PURPOSE OF DISCLOSURE (
):
C. RECORDS AUTHORIZED TO RELEASE:
I authorize the following confidential employer unemployment insurance program information and records to be
released to the third party entity identified in Section B. I understand State governmental files will be accessed
to provide the requested information/records. The identified third party entity is only authorized to use the
requested information/records for the stated purpose. State records being released to include time period:
D. SIGN REQUEST FOR RECORDS
By signing below I declare under the penalty of perjury under the laws of the State of Washington that I am the
business owner or an authorize representative of the employer whose confidential unemployment insurance
program information and records is being requested.
PRINT NAME, TITLE AND SIGNATURE OF OWNER OR AUTHORIZED REPRESENTATIVE:
DATE REQUESTED:
X
MAILED OR FAXED IN REQUESTS WILL BE RESPONDED TO WITHIN 5 TO 10 BUSINESS DAYS. SEND REQUEST TO:
ESD Records Disclosure Unit P.O. Box 9046 Olympia WA 98507-9046
Fax: 1-866-610-9225
Any questions contact the ESD Records Disclosure Unit at 1-844-766-8930
Rev. 08/2019