Fillable See Section D if requesting confidential unemployment insurance (Microsoft)

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See Section D if requesting confidential unemployment insurance (Microsoft)

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GENERAL PUBLIC RECORDS REQUEST
See Section D if requesting confidential unemployment insurance program records on an individual or employer.
A. REQUEST FOR RECORDS BY:
NAME LAST FIRST MIDDLE
TITLE (IF APPLICABLE)
ORGANIZATION OR BUSINESS NAME (IF APPLICABLE)
MAILING ADDRESS CITY STATE ZIP CODE
TELEPHONE NUMBER (INCLUDE AREA CODE)
FAX NUMBER (INCLUDE AREA CODE)
E-MAIL ADDRESS
B. DESCRIBE SPECIFIC RECORDS BEING REQUESTED:
IF REQUESTING RECORDS ON A SPECIFIC INDIVIDUAL OR EMPLOYER THEN PROVIDE NAME OF SUBJECT
IF REQUESTING RECORDS ON A SPECIFIC INDIVIDUAL OR EMPLOYER THEN PROVIDE IDENTIFYING NUMBER (i.e. SSN, UBI, etc)
DESCRIBE RECORDS BEING REQUESTED:
C. NOTIFICATION OF CHARGES FOR RECORDS:
Notify me of any cost for records that exceeds $ before providing the requested records.
D. SIGN REQUEST FOR RECORDS
Unemployment Insurance program records on an individual or employer are considered private and
confidential under Chapter 50.13 RCW. With few exceptions, non-governmental requestors may not access
such information without a signed release or a subpoena in compliance with RCW 50.13.070. There are other
agency request forms to use for an individual or employer to request a copy of their own records or to consent
to release of their records to a third party entity at
esd.wa.gov/newsroom/public-records
I declare under the penalty of perjury under the laws of the State of Washington that I will not use the
requested records for commercial purposes.
SIGNATURE:
X
REQUEST FOR RECORDS MAY BE SENT TO:
Employment Security Department Fax 1-866-610-9225
Attn: Records Disclosure Unit Phone 1-844-766-8930
P.O. Box 9046
Olympia WA 98507-9046
Rev. 08/2019
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Completed 23 August 2021

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