"Authorization to Release Records - Individual" - Washington

Authorization to Release Records - Individual 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;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Washington State Employment Security Department.

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Authorization to Release Records - Individual
A. AUTHORIZATION TO DISCLOSE CONFIDENTIAL UNEMPLOYMENT INSURANCE PROGRAM RECORDS:
FIRST MIDDLE LAST NAME OF INDIVIDUAL
SOCIAL SECURITY NUMBER (NEED TO PROCESS REQUEST):
B. DISCLOSE 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
STATE PURPOSE OF DISCLOSURE (
):
C. RECORDS AUTHORIZED TO RELEASE:
I authorize the following confidential 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.
A copy of my Wages Reported by employers in the State of Washington from
through
(start date – far back as 1987)
(end date)
A copy of my Unemployment Payment History from:
through
(start date)
(end date)
If just requesting a copy of individual’s wages reported and/or unemployment payment history then
upload and submit this signed release on-line to receive a response within 1 business day at
esd.wa.gov/newsroom/public-records
If releasing other records other than the above (identify here):
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
individual whose confidential unemployment insurance program information and records is being requested:
SIGNATURE (REQUIRED – ELECTRONIC SIGNATURE NOT ACCEPTED):
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 - Individual
A. AUTHORIZATION TO DISCLOSE CONFIDENTIAL UNEMPLOYMENT INSURANCE PROGRAM RECORDS:
FIRST MIDDLE LAST NAME OF INDIVIDUAL
SOCIAL SECURITY NUMBER (NEED TO PROCESS REQUEST):
B. DISCLOSE 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
STATE PURPOSE OF DISCLOSURE (
):
C. RECORDS AUTHORIZED TO RELEASE:
I authorize the following confidential 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.
A copy of my Wages Reported by employers in the State of Washington from
through
(start date – far back as 1987)
(end date)
A copy of my Unemployment Payment History from:
through
(start date)
(end date)
If just requesting a copy of individual’s wages reported and/or unemployment payment history then
upload and submit this signed release on-line to receive a response within 1 business day at
esd.wa.gov/newsroom/public-records
If releasing other records other than the above (identify here):
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
individual whose confidential unemployment insurance program information and records is being requested:
SIGNATURE (REQUIRED – ELECTRONIC SIGNATURE NOT ACCEPTED):
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