EMPLOYMENT SECURITY DEPARTMENT

Self-Request for Records

**THIS PAGE NEEDS TO BE COMPLETED & RETURNED ALONG WITH PROOF OF INCOME RECORDS**
**NOTE: PLEASE MAKE ANOTHER COPY OF THIS FORM FOR ADDITIONAL NAMES**

I. A RESPONSE TO YOUR REQUEST WILL BE SENT WITHIN 5 BUSINESS DAYS. PLEASE PROVIDE THE
FOLLOWING INFORMATION:

Tam Nguyen 536

NAME 1: SSN #: - 15 - 5049

NAME 2: SSN #: - -

NAME 3: SSN #: - -

NAME 4: SSN #: - -

**NOTE: PLEASE MAKE ANOTHER COPY OF THIS FORM FOR ADDITIONAL NAMES.

II. THE RECORDS BEING REQUESTED:

**I AM REQUESTING A COPY OF MY EMPLOYMENT HISTORY FOR THE MOST RECENT YEAR.
**I AM REQUESTING A COPY OF MY UNEMPLOYMENT PAYMENT HISTORY FOR THE MOST RECENT YEAR.

III. AUTHORIZATION AND SIGNATURE:

PLEASE MAIL TO:

FAX TO:
EMAIL TO:

I AUTHORIZE THE REQUESTED INFORMATION/RECORDS BE RELEASED AND SENT TO

CITY OF SEATTLE UTILITY ASSISTANCE PROGRAM(S).

BY SIGNING BELOW, I DECLARE UNDER THE PENALTY OR PERJURY UNDER THE LAWS OF THE
STATE OF WASHINGTON THAT I AM THE INDIVIDUAL WHOSE RECORDS ARE BEING REQUESTED.
tam nguyen 03/05/2024
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