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Uia 6102 Authorization To Release Confidential Information Form - Unemployment Insurance Agency Page 2

UIA 6102

(Rev. 5-15)

Page 2

Your Authorization to Release Your Information

I, __________________________________, authorize the UIA to release the information

(Printed name of worker or employer)

described above. This information will only be used for the purpose indicated.

I understand

that, except as provided in the law, the information shall not be used in any action or proceeding

before any court or administrative tribunal unless the Agency is a party to, or a complainant in,

the action or proceeding, or unless used for the prosecution of fraud, civil proceeding, or other

legal proceeding in the programs indicated in Section 11(b)(2) of the MES Act. Any person

who willingly violates the provisions of this Act is subject to the penalty provisions of Michigan

Compiled Laws (MCL) 421.54.

_____________________________________________________________________________

Signature of Worker/Employer

-or-

_____________________________________________________________________________

Signature of Worker’s/ Employer’s Authorized Representative

A copy of your appearance must be attached otherwise records will not be released.

________________________

Date:

If you have any questions about this Form contact the UIA at 1-313-456-3435 (TTY customers use

1-866-366-0004).

For additional information contact:

Unemployment Insurance Agency

FOIA Coordinator

3024 W. Grand Blvd., Suite 13-600

Detroit, MI 48202

Fax:

1-313-456-2316

LARA is an equal opportunity Employer/Program..

Uia 6102 Authorization To Release Confidential Information Form - Unemployment Insurance Agency Page 2