Form SSA-581 Authorization to Obtain Earnings Data from the Social Se

Form Approved
OMB No. 0960-0602

Social Security Administration

Authorization to Obtain Earnings Data from the
Social Security Administration

Mail
completed
form to:

Social Security Administration
Requesting
Wilkes Barre Data Operations Center organization:
PO Box XXXX
1150 East Mountain Drive
Wilkes Barre, PA XXXXX

RA PENF 09 XXXX
Pension Fund Name
Street
City, State, ZIP

Number Holder's Information
Middle Initial:

First Name:
Last Name:

--

--

SSN:

--

--

Date of Birth:
Month

Day

Year

--

--

Date of Death:
Month

Day

Year

Other First,
Middle Initial,
and Last Name
Used to Report
Earnings:
Periods
Requested:

-Month

--

through
Year

Month

-Month

through
Year

Year

-Month

Year

I am the individual to whom the record/information applies or that person's parent (if a minor) or legal guardian, or a person
who is authorized to sign on behalf of the individual to whom the record/information applies. Please furnish the requesting
organization, or its designees, an itemized statement of all amounts of earnings reported to my record, or to the record
identified above, for the periods specified on this form. Please include the identification numbers, names, and addresses of
the reporting employers. I declare under penalty of perjury that I have examined all the information on this form, and
on any accompanying statements or forms, and it is true and correct to the best of my knowledge.

Signature of Number Holder (or authorized representative)

Date

Printed Name (if other than number holder)

--

--

Relationship (if other than number holder)
Natural or adoptive parent

Address

Legal Guardian

State

Other (specify) ______________

City

ZIP Code

Phone Number

Requesting Organization's Information
Date

Signature of Organization Official
Phone Number
FOR SSA USE ONLY
Form SSA-581-OPXXX (XX-2009)
Destroy Prior Editions

Fax Number
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IMPORTANT INFORMATION
Privacy Act Notice
Section 205 (c) (2) (A) of the Social Security Act allows us to ask for the information you give us on this form.
The information is needed so that the Social Security Administration can quickly identify your record or the record
of the deceased individual who is the subject of a request you are making and prepare the earnings statement you
want. You do not have to give us this information. However, without the information we may not be able to
process your request. The information you provide will be used primarily for issuing the earnings statement you
request. The information you provide may be given out if a Federal law requires that we give out the information;
if a Congressman or the President's office needs this information to answer questions you ask them; or the
Department of Justice needs the information for investigating or prosecuting violations of the Social Security Act.
We may also use the information you give us when we match records by computer. Matching programs compare
our records with those of other Federal, State, or local government agencies. Many agencies may use matching
programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us
to do this even if you do not agree to it.
Explanations about the reasons why information you provide us may be used or given out are available in Social
Security offices. If you want to learn more about this, contact any Social Security office.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of
Management and Budget control number. We estimate that it will take 2 minutes to read the instructions, gather
the facts, and answer the questions. You may send comments on our time estimate above to SSA, 6401 Security
Boulevard, Baltimore, MD, 21235-6401. Send only comments relating to our time estimate to this address,
not the completed form.

Form SSA-581-OPXXX (XX-2009)

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