Release Of Information
Download a blank fillable Release Of Information in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Release Of Information with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1RELEASE OF INFORMATION
Please print all names you have gone by in the last 5 years.
NAME OF APPLICANT: _________________________________________________
SOCIAL SECURITY: ___________________________________________________
DATE: _________________________________________________________________
I authorize the Indiana Department of Workforce Development to release all wage and
unemployment benefit information to the agency listed below.
_____________________________________________
SIGNATURE OF APPLICANT
Check this box if Power of Attorney is attached
By signing below you agree that you understand that data we release to you is protected
under state law (IC 22-4-19-6) and federal regulations (20 CFR § 603.5) as confidential
information. You also confirm that you have verified the applicant’s identity by viewing
some type of photo identification.
Signature of Requestor: ___________________________________
Brightpoint
Requesting Agency: ______________________________________
1-844-510-5775
Fax Number: ___________________________________________
1-800-589-3506
Phone Number: _________________________________________
For questions email
EmployVerification@dwd.IN.gov
or call 317-233-2696.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal