Form 480 - Individual Confidential Information Request
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1Form 480 (Rev. 9/2012) ADOL
Cat. No. 52001 (previous
versions obsolete)
ALABAMA DEPARTMENT OF LABOR
INDIVIDUAL CONFIDENTIAL INFORMATION REQUEST
1. This form allows you to request information from your own file. It must be completed with a notarized
signature and include a money order made payable to "ADOL" in the amount of $10.00 (ten dollars). If you
Information Disclosure Unit at (334)242-8981
have questions regarding this notice, please call the
.
THIS FORM IS FOR CLAIMANT REQUESTS ONLY. If you are an attorney or represent the
claimant listed below in a legal action, please contact the ADOL Legal Division at 334-242-8376 for
assistance.
2. Please select the information needed: (Check all that apply)
UC Claimant Profile printout
-
Shows your total Unemployment Compensation (UC) benefit amount and balance.
It contains your name, address, phone number, and beginning and ending dates of the
claim.
UC Base Period Wages printout -
Shows your reported Alabama wages by quarter.
UC Payment History printout
- Shows your weekly UC payments during the benefit year.
Other (specify) ______________________________________________________________________
3. All requests are $10.00 and must be prepaid. Mail money order payable to "ADOL" to:
Central Cashier
Alabama Department of Labor
649 Monroe Street, Room 2684
Montgomery, AL 36131
4. The Alabama Department of Labor is hereby authorized to release the requested
information from my records.
(PRINT) Full Name
Social Security Number
5.
My Phone Number is:
(
)
Area Code
Telephone Number
6.
The above information is to be used for the following purpose(s) ______________________________
7.
Please
mail my information to the address below or
FAX it to (
)
Area Code
Fax Number
Name
Address
City ________________________________ State _______ ZIP
8.
Notarized signature: (Please sign this form in the presence of a Notary only.)
Claimant’s Signature
Notary Signature
(Notary Seal)
Date Notarized
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