Looking for a Michigan Legal Forms And Templates? Download it for free!

UIA 6102

Authorized by

(Rev. 5-15)

MCL 421.1, et seq.

State of Michigan

Talent Investment Agency

UNEMPLOYMENT INSURANCE AGENCY

Authorization to Release Confidential Information

Section 11(b) of the Michigan Employment Security (MES) Act provides that information in the files of the Michigan

Unemployment Insurance Agency (UIA) is confidential, and that information regarding a claim for unemployment benefits

or wages, may only be released to the claimant and/or employer involved in the claim, to the partially chargeable employer

involved in the claim, or the employer directly involved in a possible ineligibility or disqualification of a claimant who paid

the wages. Information may also be released to other departments of this state and to certain federal agencies. This Form

allows you to give your permission for the release of the specifically described information to the specifically described

entity for the specified purpose. The purpose specified in the release shall be limited to a service or benefit to the individual

signing the release or carrying out administration or evaluation of a public program to which the release pertains.

Interested parties and/or their representative(s) may obtain records for UIA proceedings at

no cost. To avoid receiving an invoice for documents received, your request must include

a statement that you are, or that you represent the claimant or employer, and that you are

requesting records in connection with a protest or appeal. If you are a representative and

have an appearance on file, please attach a copy of your appearance.

Release requested by:

Claimant

Employer

Other:________________________________________

Name:__________________________________ Address: _______________________________________________

(Please Print)

Last name

First

City

Zip Code

Telephone number:_______________________

Social Security Number:_________________

Name of Business:______________________________ Address:__________________________________________

City

Zip Code

Telephone number:_______________________ UIA Account number:__________________ FEIN:____________

List all the other individuals and entities to whom the UIA information requested will be

redisclosed:

Name:____________________________

Company/Organization/Agency: _________________________

Address: _________________________________________________________________________

City

Zip Code

List all the other individuals and entities to whom the UIA information requested will be

redisclosed:

Name:____________________________

_______________________

Company/Organization/Agency:

Address: _________________________________________________________________________

City

Zip Code

Indicate the specific purpose for which the information is sought: _______________________

________________________________________________________________________________

Specify information and time period (up to 8 quarters for wages) to be released: ___________

________________________________________________________________________________

Uia 6102 Authorization To Release Confidential Information Form - Unemployment Insurance Agency

Related Articles

Related forms

Related Categories