Authorization To Release Employee Benefits Information Form. This is a Missouri form and can be use in 38th Circuit Local Circuit Courts.
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.: American LegalNet, Inc. www.USCourtForms.com