Form Modes-4385 - Employer Records Release Authorization Page 2
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2Acknowledgment of Confidentiality by Proposed
Recipient of Confidential Information
I understand that the Unemployment Insurance information requested from the Division of Employment Security
in the records release authorization remains confidential and may only be used by the party gaining access to the
information for the limited purpose for which it is provided. Any further dissemination, use, or release of the
Unemployment Insurance information obtained from the Division of Employment Security is strictly prohibited under the
provisions of Section 288.250, RSMo and 20 CFR part 603, and substantial penalties will result if the confidentiality of
the information is not maintained by the party requesting the information. By signing this document, the party receiving
said information acknowledges and agrees that the information received will be safeguarded and will only be used by the
party gaining access to the information for the limited purpose for which the information is being provided. The party
receiving this information agrees that the state of Missouri has the right to inspect and audit its records to assure that the
information being provided remains confidential, and that the confidentiality provisions of the Missouri Employment
Security Law, Chapter 288, RSMo, and 20 CFR part 603 are followed.
Recipient agrees that he/she will promptly and confidentially destroy all information received from the Division
as soon as such information is no longer needed for the specific purpose upon which it was obtained. Recipient further
agrees that the state of Missouri may, at any time, demand the return of all confidential information and written assurance
by the party who received the information that all of the furnished information has been returned to the Division of
Employment Security, and that all copies have been destroyed by the party receiving the information.
A copy of this document whether typewritten or made by machine, shall have the force and effect as the original.
List all persons who will have access to confidential information obtained under this form (attach additional
sheets, if necessary): ________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________
Signature
__________________________________________________
Typed Name
__________________________________________________
Title or relationship to party authorized to receive documents
STATE OF MISSOURI
)
) ss.
County of ______________________ )
On this _____ day of __________________, _____, before me, a notary public, appeared
_______________________________________________________ who executed the foregoing
acknowledgment of confidentiality and acknowledged the same as his/her free act and deed.
__________________________________________________
Notary Public
____________________________________________
My Commission Expires:
Return completed form to:
Confidential Information Coordinator
Missouri Department of Labor and Industrial Relations
Division of Employment Security
P.O. Box 59
Jefferson City, MO 65104-0059
MODES-4385-2 (09-11) AI
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