MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 
                                 EMPLOYER RECORDS RELEASE AUTHORIZATION 
                                 
To Whom It May Concern: 

__________________________________________________, the employer, understands that Division 
of Employment Security records are confidential pursuant to Section 288.250 RSMo and 20 CFR part 603, and 
may only be used by the party authorized for the limited purpose for which the information was requested. The 
employer hereby authorizes the Division of Employment Security, an agency of the Missouri Department of 
Labor and Industrial Relations, to release information concerning unemployment insurance tax account 
__________________________________________ that the employer has submitted to or received from the 
Division. The information to be released is listed as follows: _________________________________________ 
__________________________________________________________________________________________ 
for the time period of _________________________________. 
These documents shall be released to ____________________________________ or any representative 
designated by them and be used solely for the purpose of ___________________________________________. 
This authorization includes the rights of the persons hereby authorized to inspect and copy or photocopy such 
records, information, and evidence. I understand that state government files will be accessed to provide this 
information. 
A copy of this document, whether typewritten or made by machine, shall have the force and effect as the 
original. 

                                             __________________________________________________ 
                                             Signature of Employer or Agent 

                                             __________________________________________________ 
                                             Title 

          STATE OF MISSOURI      ) 
                                 )  ss. 
          County of ______________________ ) 

             On this _______ day of __________________, _____, before me, a notary public, 
          appeared __________________________________________ who executed the foregoing 
          records release authorization and acknowledged the same as his/her free act and deed. 

                                           __________________________________________________ 
                                           Notary Public 

          My Commission Expires:  ____________________________________________ 

             (Both pages of this document must be signed and notarized.) 

                                                                               MODES-4385 (06-19) AI 
                                                                                                Legal 

                      Acknowledgment of Confidentiality by Proposed 
                        Recipient of Confidential Information 
  I understand that the Unemployment Insurance information requested from the Division of Employment Security 
in the records release authorization remains confidential and may only be used by the party gaining access to the 
information for the limited purpose for which it is provided. Any further dissemination, use, or release of the 
Unemployment Insurance information obtained from the Division of Employment Security is strictly prohibited under the 
provisions of Section 288.250, RSMo and 20 CFR part 603, and substantial penalties will result if the confidentiality of 
the information is not maintained by the party requesting the information. By signing this document, the party receiving 
said information acknowledges and agrees that the information received will be safeguarded and will only be used by the 
party gaining access to the information for the limited purpose for which the information is being provided. The party 
receiving this information agrees that the state of Missouri has the right to inspect and audit its records to assure that the 
information being provided remains confidential, and that the confidentiality provisions of the Missouri Employment 
Security Law, Chapter 288, RSMo, and 20 CFR part 603 are followed. 
  Recipient agrees that he/she will promptly and confidentially destroy all information received from the Division 
as soon as such information is no longer needed for the specific purpose upon which it was obtained. Recipient further 
agrees that the state of Missouri may, at any time, demand the return of all confidential information and written assurance 
by the party who received the information that all of the furnished information has been returned to the Division of 
Employment Security, and that all copies have been destroyed by the party receiving the information. 
  A copy of this document whether typewritten or made by machine, shall have the force and effect as the original. 
  List all persons who will have access to confidential information obtained under this form (attach additional 
sheets, if necessary): ________________________________________________________________________________ 
_________________________________________________________________________________________________ 
  
                                      __________________________________________________ 
                                      Signature 
                                       
                                      __________________________________________________ 
                                      Typed Name 
                                       
                                      __________________________________________________ 
                                      Title or relationship to party authorized to receive documents 
   
  STATE OF MISSOURI          ) 
                             )  ss. 
  County of ______________________  ) 
   
   On this _____ day of __________________, _____, before me, a notary public, appeared 
  _______________________________________________________ who executed the foregoing 
  acknowledgment of confidentiality and acknowledged the same as his/her free act and deed. 
   
                                      __________________________________________________ 
                                      Notary Public 
   
  My Commission Expires:  ____________________________________________ 

   Return completed form to: Confidential Information Coordinator 
                             Missouri Department of Labor and Industrial Relations 
                             Division of Employment Security 
                             P.O. Box 3100 
                             Jefferson City, MO 65102-3100 
                                                                       MODES-4385-2 (06-19)  AI