State Form 56204 - Request For Wage Transcript

ADVERTISEMENT

Reset Form
REQUEST FOR WAGE TRANSCRIPT
State Form 56204 (12-16)
Indiana Department of Workforce Development
* This agency is requesting disclosure of your Social Security Number in accordance with IC 22-4-19-6, IC 4-1-6; disclosure is mandatory
and this record cannot be processed without it.
INSTRUCTIONS:
1.
Please print legibly in blue or black ink. Fill this sheet out completely and accurately.
2.
NOTE: All requests for wage transcripts will be sent directly to the agency requiring information for the purpose of providing
necessary social services. Information will not be provided to individuals or for individual use.
3.
All requests will be fulfilled on a first come, first served basis. Requests will not be fulfilled immediately and response time is
dependent upon request volume. For faster service, the requesting agency can request this information via Last Known Employer
(LKE) system.
*Name: __________________________________________________________________________________________
FIRST
MIDDLE
LAST
*Full Social Security Number: _____________ - ________- ____________________
*Date: __________ /__________ /_________
MM
DD
YYYY
*Your Telephone Number
(__________) ____________ - _____________________
(Include Area Code)
*Agency Name: _____________________________________________________________________________________
(The Party to which the requested information will be sent)
Case Number: (if applicable) _______________________
Attention: __________________________________________
*Agency Telephone Number:
(_________) __________ - ________________
(Include Area Code)
*Fax:
(_________) __________ - _____________
(Include Area Code)
Comments:
_______________________________________________________________________________________
__________________________________________________________________________________________________
*Required

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go