Form Modes-4385 - Employer Records Release Authorization
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2MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
EMPLOYER RECORDS RELEASE AUTHORIZATION
To Whom It May Concern:
__________________________________________________, the employer, understands that Division
of Employment Security records are confidential pursuant to Section 288.250 RSMo and 20 CFR part 603, and
may only be used by the party authorized for the limited purpose for which the information was requested. The
employer hereby authorizes the Division of Employment Security, an agency of the Missouri Department of
Labor and Industrial Relations, to release information concerning unemployment insurance tax account
__________________________________________ that the employer has submitted to or received from the
Division. The information to be released is listed as follows: _________________________________________
__________________________________________________________________________________________
for the time period of _________________________________.
These documents shall be released to ____________________________________ or any representative
designated by them and be used solely for the purpose of ___________________________________________.
This authorization includes the rights of the persons hereby authorized to inspect and copy or photocopy such
records, information, and evidence. I understand that state government files will be accessed to provide this
information.
A copy of this document, whether typewritten or made by machine, shall have the force and effect as the
original.
__________________________________________________
Signature of Employer or Agent
__________________________________________________
Title
STATE OF MISSOURI
)
) ss.
County of ______________________
)
On this _______ day of __________________, _____, before me, a notary public,
appeared __________________________________________ who executed the foregoing
records release authorization and acknowledged the same as his/her free act and deed.
__________________________________________________
Notary Public
____________________________________________
My Commission Expires:
(Both pages of this document must be signed and notarized.)
MODES-4385 (09-11) AI
Legal
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