Indiana Workforce 

Development

(Yellow Form)

Release of Information

Name of Applicant
Date

I authorize the Indiana Department of Workforce Development to release all wage and unemployment benefit information to the agency listed below.

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By signing below you agree that you understand that data we release to you is protected under state law (IC 22-4-19-6) and federal regulations (20 CFR & 603.5) as confidential information. You Also confirm that you have verified the applicant's Identity by viewing some type of photo identification.

NOTE: RELEASE MUST BE SUBMITTED WITHIN 90 DAYS OF APPLICANT SIGNING RELEASE FORM.

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Requesting Agency: Washington Township Trustee, Avon

Fax Number: (317) 272-2733

Phone Number: (317) 272-1835 x2

For Questions Email: EmployVerification@dwd.IN.gov


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