Self request: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by providing your personal information in Section 1. Enter your full name, including any aliases or maiden names, and your Social Security Number to ensure accurate processing of your request.
In Section 2, check one or more boxes to specify the records you are requesting. You can choose to receive a copy of your Wages Reported by employers or your Unemployment Payment History. Be sure to fill in the start and end dates for the records you need.
If you require additional records not listed, please identify them in the space provided in Section 2.
Proceed to Section 3 for Authorization and Signature. Fill out the recipient's details, including first name, last name, organization (if applicable), address, and contact information.
Finally, sign and date the form at the bottom of Section 3. Remember that electronic signatures are not accepted.

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