Missouri > Local Circuit Courts > 38th Circuit > Dissolution
Authorization To Release Employee Benefits Information 7 - Missouri
| Authorization To Release Employee Benefits Information Form. This is a Missouri form and can be used in Dissolution 38th Circuit Local Circuit Courts . |
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AUTHORIZATION TO RELEASE EMPLOYEE BENEFITS INFORMATION To: ____________________________________ ____________________________________ ____________________________________ Re: Your Employee:_______________________ Social Security No. You are hereby authorized and requested to furnish and release to ____________________ and to any employee, agent or representative thereof any and all information in your possession or under your control concerning my employment and fringe and retirement benefits. You are further authorized to allow said persons to read, review, copy and have copied any and all records, notations, memoranda, and all other recorded information regardless of whether it is written, recorded, on comerized disc, etc. with respect to all aspects putof my employment from the date I began my employment to the present date. You are further authorized to communicate with said persons orally or in writing concerning the matters addressed herein. The information you are authorized to release shall include, but not be limited to: my earnings, wages, other forms of compensation, m emy ployee benefits, fringe benefits, profit sharing, retirement and/or pension benefits, health, dental, vision, life insurance and disability benefits, performance records, attendance records, employer/employee investment plans, stock plans, savings plans, thrift plans, employee stock option plans, 401K, deferred compensation, supplemental or excess benefit plans, "golden parachute" or "silver seatbelt" provisions, vested bonus not yet paid, zero balance reimbursement accounts, and employment-related trusts. __________________________________________ STATE OF MISSOURI ) ) ss COUNTY OF ) On this ____ day of ___________, _____, before me a Notary Public, personally appeared the above named person who acknowledged signing the above and foregoing instrument as a free act and deed. __________________________________________ N otary Public My Commission Expires: th 38 Circuit Form 7 (Rev. 1-1-2000)
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