CAPE

Release of Information


Applicant's Name:

Additional names used during employment:

Social Security or Individual Tax Identification Number:

Email Address:

Phone Number:

Street Address:

City: Zip Code:

I authorize the Indiana Department of Workforce Development to release all wage and unemployment benefit information to the organization below.

NOTE: RELEASE MUST BE SUBMITTED WITHIN 90 DAYS OF APPLICANT SIGNING RELEASE FORM.

Attached Power of Attorney Documents (Optional):


NOTE: This section must be completed by the organization requesting employment history.

By signing below you agree that you understand that data we release to you is protected under state law (IC 22-4-19-6) and federal regulations (20 CFR § 603.5) as confidential information. You also confirm that you have verified the applicant's identity by viewing some type of photo identification.

Requesting Organazation: Community Action Program of Evansville (CAPE)

Phone Number: (812) 492-3908 Fax Number: (812) 452-3129

Email employverification@dwd.in.gov to reach a DWD employment history or LKE website specialist.

Leave this empty:

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Signature Certificate
Document name: Release of Information
lock iconUnique Document ID: b9f567479d43def3e5d7a8363ac30751b5fecd97
Timestamp Audit
April 21, 2021 3:34 pm CDTRelease of Information Uploaded by Joe Massaro - jmassaro@capeevansville.org IP 96.27.254.146