RELEASE OF INFORMATION AUTHORIZATION 
                            JOB SERVICE NORTH DAKOTA 
                            UNEMPLOYMENT INSURANCE 
                            SFN-54485 (R. 02-19) 
                            
  Last Name                                      First Name                                                         Middle Initial 

  Social Security Number*                                                                   Date of Birth 

  Street Address/Post Office Box                  City                                      State                   ZIP Code 

            I HEREBY AUTHORIZE JOB SERVICE NORTH DAKOTA TO RELEASE THE INFORMATION 
                                          REQUESTED IN THIS RELEASE TO 
  Recipient (Name of Person/Organization)          Recipient Organization Type (Be Specific) 

  Street Address/Post Office Box 

  City                                                                     State                  ZIP Code 

  Recipient - check the appropriate boxes for information needed: 
  
  Individual is currently receiving Unemployment Compensation. Yes                                No                 

  Date of initial payment                         Weekly benefit amount                                                               
  Balance of benefits                              
  Wage history:  Start - year and quarter (yy/q)                         /    .  End - year and quarter (yy/q)                     /  . 
  Listing each purpose, identify how the above information will be used. 

                                                 PARTICIPANT CONSENT 
  This authorization is voluntary and is applicable only to this transaction and for the requested information listed above. A photocopy of 
  this authorization is as effective as the original. Unless otherwise agreed to in writing, information may be disclosed under this 
  authorization in any form or medium, including oral, written, or electronic transmission. 
  Signature of Participant                                                                  Date 

  Signature of Parent or Guardian (Required if applicant is under age 18.)                  Date 

  Signature of Witness (if needed)                                                          Date 

  Notice: to whomever disclosure is made. This information has been disclosed to you from confidential government records. You are 
  prohibited from making any further disclosure of this information unless further disclosure is expressly permitted by the written 
  authorization of the person to whom it pertains, or as otherwise permitted by law. 
 
  *In compliance with the Privacy Act of 1974, a Social Security Number is mandatory on this form pursuant to 20 CFR 666.150 and/or North Dakota 
  Century Code 52-02-02. This number is used by Job Service North Dakota for identification, federal and state tax program eligibility purposes, and 
  program performance accountability. 
 
       Submit To: Release of Information Officer Unemployment Insurance PO Box 5507 Bismarck ND 58506-5507 Fax 701-328-2728 
 
                            Job Service North Dakota is an equal opportunity employer/program provider. 
                           Auxiliary aids and services are available upon request to individuals with disabilities.