* 1. Washington law allows disclosure of confidential information with the consent of the individual or employer whose information will be disclosed. With written consent from the individual or employer, you will not be required to provide additional information to support your request for data-sharing. Do you have a signed, written consent that authorizes release of the requested information?

Yes No

* 2. Please provide a detailed explanation of the purpose for which confidential information is requested (maximum 2,000 characters).

* 3. List the federal or state laws that authorize your organization to receive confidential information from ESD (maximum 2,000 characters). Include all applicable citations. Refer to 20 CFR 603.5, 50.13.050, 50.13.060, 50.13.070, 50.38 , 39.34 or 9.94A.760 for more information.

* 4. Please describe the confidential information requested by listing the data elements (quarterly wages, claims, and/or services).Indicate geographical area, time period, and industry if applicable (maximum 2,000 characters).

* 5. How would your organization like to receive this confidential data?

* 6. Please state the duration and frequency of which the information will be needed.

* Request duration of data-sharing agreement:

* 7. Briefly describe how the confidential information will be protected from unauthorized use or re-disclosure by employees, contractors or third parties (maximum 2,000 characters).