Form K-Rm 002 - Request For Disclosure Of Tax/benefit Information
Download a blank fillable Form K-Rm 002 - Request For Disclosure Of Tax/benefit 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 Form K-Rm 002 - Request For Disclosure Of Tax/benefit 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
1KANSAS DEPARTMENT OF LABOR
MAIL TO: Disclosure Officer
Kansas Department of Labor
REQUEST FOR DISCLOSURE OF
P.O. Box 3539
Topeka, KS 66601-3539
TAX/BENEFIT INFORMATION
FAX TO: (785) 368-7117
K-RM 002 (Rev. 8-13)
___________________________________________________________________________________
Information requested:
_______________________________________________________________________________________________________________
Information will be used for: _________________________________________________________________________________________
_______________________________________________________________________________________________________________
SECTION A – CLAIMANT
SECTION B – EMPLOYER
This request is submitted by an employer or in reference to a
This request is submitted by a claimant or in reference to a Kansas
unemployment claimant. Information requested by a claimant
Kansas employer’s account.
will only be mailed to the claimant.
Employer account number: ________________________________
Claimant Social Security number: __________________________
Employer name: ________________________________________
Claimant name:_________________________________________
Unemployment tax returns:
Claimant address: _______________________________________
Quarters ____________________ Years ____________________
City: ____________________ State: ______ ZIP: ______________
SECTION C – PUBLIC OFFICER OR EMPLOYEE
This request is submitted in the performance of public duties by an authorized officer or employee of:
__________________________
___________________________
Local government branch name:
Federal government branch name:
___________________________
____________________________
Law enforcement agency name:
State government branch name:
_____________________________________________
Other:
Send information to: _______________________________________________________________________________________________
_______________________________________________________________________________________________________________
Information maintained in the KDOL files may only be disclosed as provided for in K.A.R. 50-4-2 and K.S.A. 44-714(e).
CERTIFICATION: I understand this information is being released in accordance with the Employment Security Law, K.S.A. 44-714(e),
which provides for disclosure of information to…“public employees in the performance of their public duties…” The information retains its
confidential nature and “…shall not be published or be open to public inspection… in any manner revealing the individual’s or employing
unit’s identity…” I further understand this information is being supplied with the express understanding that the recipient will treat this
information in a confidential manner and refrain from disclosing the information or allowing it to be published as part of a public record in
any proceeding.
(SIGNATURE MUST BE NOTARIZED)
By my signature, I further authorize and consent to the disclosure and copying of these records for the above mentioned purposes. I
further attest that I acknowledge the guidelines of disclosure as mentioned in K.A.R. 50-4-2 and K.S.A. 44-714(e).
Requestor printed name: __________________________________ Title
: _____________________________________
(if applicable)
Signature:____________________________________
Date:________________
Phone: _________________________________
BE IT REMEMBERED, that on this _______ day of _______________, 20____, before me personally
appeared _____________________________________, known to me to be the person named in and
who executed the foregoing instrument of writing and acknowledges the execution of the same.
State of ________________________
NOTARY PUBLIC:_________________________________
County of _______________________
My commission expires on:__________________________
RECORDS MANAGEMENT
P.O. Box 3539, Topeka, KS 66601-3539 • Phone: (785) 296-5072 • Fax: (785) 368-7117
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal