Social Security Release Form {115}

Form 115 Adopted 1/ 1/97 KENTUCKY DEPARTMENT OF WORKERS CLAIMS SOCIAL SECURITY R ELEASE FORM I, ___________________________, having filed an Applcatii on for Resolutionof Occupational Disease or Hearing Loss Claim for workers compensation benefits, do hereby authorize the Social Security Administration to release or disclose to the Department of Workers Claims any information in their possession concerning my benefit or wage earnings. Signed at ______________________, Kentucky, this _______ day of ______________________, 20____. ______________________________ Plaintiffs Signature ______________________________ Social Security Number ________________________ Witness Signature