Authorization To Release Employee Benefit Information {1402H} | Pdf Fpdf Doc Docx | Missouri

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Authorization To Release Employee Benefit Information {1402H} | Pdf Fpdf Doc Docx | Missouri

Authorization To Release Employee Benefit Information {1402H}

This is a Missouri form that can be used for Family Court within Local Circuit Courts, 16th Circuit (Jackson County).

Alternate TextLast updated: 5/8/2006

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AUTHORIZATION TO RELEASE EM PLOYEE BENEFIT INFORMATION To:_______________________ _______________________ _______________________ Re: Your Employee __________________ Soc. Sec. No. __________________ You are hereby authorized to furnish and release to ____________________ __________ ____________________________________________ and to any employee, agent or representative any and all information in your possession or under your control concerning my employment , 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 computerized disc, etc., with respect to all aspects of my employment from the date I began my employment until the present date. You are further authorized to communicate with said persons orally or in writing concerning the matters addressed within this authorization. This authorization shall expire six months from the date of signature. The information you are authorized to release shall include, but not be limited to: my earnings, wages, other forms of compensation, my employee 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, emoyee stock option plans , 401K plans, deferred pl compensation, supplemental and excess benefits, golden parachute or silver seatbelt provisions, vested bonus not yet paid, zero balance reimbursement programs, and employee related trusts. All expenses pertaining to the foregoing shall be paid by the party requesting information pursuant to this authorization, and nothing shall be construed to make me liable for the costs. __________________________ State of Missouri ) ) ss County of __________) On this _____ day of ______, 20__, before meNotary Public, personally appeared the , a above named person who acknowledged signing the above instrument as a free act and deed. ____________________________ N otary Public My commission expires: Form 1402H Adopted 1/17/03 Effective 2/19/03 <<<<<<<<<********>>>>>>>>>>>>> 2 AUTHORIZATION TO DISCLOSE FINANCIAL RECORDS To:_________________________________ _________________________________ _________________________________ Re:_________________________________ SSN______________________________ You are hereby authorized and directed to furnish and release to_____________________ _______________________________________________________ and to employee, agent or representative any and all or any portion of the records, documents , other writings, and information in your possession or under your control concerning all of my accounts with and deposits in your institution, whether open or closed, and whether held solely in my name or jointly with another and further concerning all my loans and lines of credit with your institution on which I am liable individually or jointly with another, or as a guarantor for the last three years . You are further authorized to allow said persons to read, review, copy and have copies any and all records, notations, memoranda, and all other recorded information regardless of whether it is written, recorded, or on computerized disc. You also authorized to communicate to said persons orally or in writing, and to provide reports concerning the matters addressed herein for the purpose of explaining or disclosing any other information requested relative to such accounts and deposits. This authorization shall expire six months from the date of signature. All expenses pertaining to the the foregoing shall be paid by the party requesting the information pursuant to this authorization and nothing herein shall be construed to make me liable for those costs. _________________________ State of Missouri ) ) ss County of ________ ) On this _____ day of 20___, 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. ___________________________ My commission expires: Form 1402H Adopted 1/17/03 Effective 2/19/03

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