Release of Information
Additional names used during employment:
Social Security or Individual Tax Identification Number:
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 firstname.lastname@example.org to reach a DWD employment history or LKE website specialist.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Release of Information
Agree & Sign