Self-Request For Records - Employment Security Department

ADVERTISEMENT

SELF-REQUEST FOR RECORDS
A response to your request will be sent within 5 BUSINESS DAYS.
1.
PROVIDE THE FOLLOWING INFORMATION:
Name
(please include any alias or maiden name):
Social Security Number:
-
-
CHECK ONE OR MORE BOXES TO INDICATE THE RECORDS BEING REQUESTED:
2.
I am requesting a copy of my Employment History from
through
01/01/12
Present
(start date)
(end date)
I am requesting a copy of my Unemployment Payment History from
through
01/01/12
Present
(start date)
(end date)
If you are seeking records other than the above (identify here):
AUTHORIZATION AND SIGNATURE:
3.
a) Mail or Fax records to:
b)Send Request to:
ATTN:
City of Seattle
Employment Security Department
Utility Discount Program
Attn: Records Disclosure Unit
rd
810 3
Ave, Ste 350
P.O. Box 9046
Seattle, WA 98104
Olympia WA
98507-9046
Phone (206) 684-0268
Phone:
(360) 407-4580
FAX: (206) 621-5012
FAX:
(866) 610-9225
c) I authorize the requested information/records be released and sent
to the entity identified in Section 3a.
d) By signing below I declare under the penalty of perjury under the
laws of the State of Washington that I am the individual whose
records are being requested.
X
_________________________________
________________________
Signature (Required)
Date
Rev. 05/09

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go