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Authorization To Release Employee Benefits Information Form. This is a Missouri form and can be use in 38th Circuit Local Circuit Courts.
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Tags: Authorization To Release Employee Benefits Information, 7, Missouri Local Circuit Courts, 38th Circuit
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
Calendar No.
:
JUDICIAL SUBPOENA
-against:
AUTHORIZATION TO RELEASE
EMPLOYEE BENEFITS INFORMATION
:
To:
____________________________________
____________________________________
Defendant(s)
____________________________________
:
:
......................................................
Re:
Your Employee:_______________________
Social Security No.
THE PEOPLE OF THE STATE OF NEW YORK
You are hereby authorized and requested to furnish and release to
TO
____________________ and to any employee, agent or representative thereof any and all
information in your possession or under your control concerning my employment and fringe and
retirement benefits. You are further authorized to allow said persons to read, review, copy and
have copied any and all records, notations, memoranda, and all other recorded information
GREETINGS:
regardless of whether it is written, recorded, on computerized disc, etc. with respect to all aspects
of my employment from the date allbegan my employment to laid aside, you and each of you attend before
I
the present date. You are further
WE COMMAND YOU, that business and excuses being
authorized
writing concerning the matters
,
the Honorable to communicate with said persons orally or in Court
at the
addressed herein.
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
The information you are authorized witness in shall include, but not be
or adjourned date, to testify and give evidence as a to release this action on the part of the limited to: my
earnings, wages, other forms of compensation, my employee benefits, fringe benefits, profit
sharing, retirement and/or pension benefits, health, dental, vision, life insurance and disability
benefits, performance records, attendance records, employer/employee investment plans, stock
Your failure to
plans, savings plans, complyplans, employee stock option as a contempt of court and will make you liable to
thrift with this subpoena is punishable plans, 401K, deferred compensation,
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
supplemental or to comply.
result of your failureexcess benefit plans, "golden parachute" or "silver seatbelt" provisions, vested
bonus not yet paid, zero balance reimbursement accounts, and employment-related trusts.
Witness, Honorable
Court in
County,
STATE OF MISSOURI
COUNTY OF
, one of the Justices of the
day of
)
) ss
)
, 20
__________________________________________
(Attorney must sign above and type name below)
Attorney(s) for
On this ____ day of ___________, _____, before me a Notary Public, personally
appeared the above named person who acknowledged signing the above and foregoing
instrument as a free act and deed.
Office and P.O. Address
__________________________________________
Notary Public
My Commission Expires:
38th Circuit Form 7 (Rev. 1-1-2000)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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