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SAMPLE AUTHORIZATION FORM
Dear Plan Administrator: Consent is hereby given to you to provide  ,Esq. of the law firm of Address: Phone:  Fax:with any and all information they may request or require concerning my retirement benefits, other employment benefits, and employment history (including dates of employment and salary history). This authorization is strictly limited to my employment benefits and history, not to nonfinancial, nonbenefit personnel matters. In addition, this authorization will expire 365 days from the date of notarization. If not dated, this authorization will expire 365 days from your receipt of this request. To facilitate handling this matter, I authorize you to reveal this information by phone, letter, or fax to my authorized agents. In addition, I ask that you honor faxed transmissions of this authorization form or copies thereof, recognizing that the original will be forwarded, if requested, for your records. If there are any questions concerning this authorization, please contact me promptly at: Signature: Date:
Name: Print Name of Employee Social Security # of Employee Phone: Fax:
Address: 
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