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:

Year

Month

--

through

--

Month

through

-Month

Year

-Month

Year

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
1

2

3
Page 1

4

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

See Revised PRA
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)

Page 2

SSA will insert the following revised Privacy Act Statement into the form
at its next scheduled reprinting:
Privacy Act Statement
SSA 581 (Authorization to Obtain Earnings Data from the Social Security
Administration)
Sections 205(a), 205(c)(2), and 223 of the Social Security Act, as amended, authorize us
to collect the information requested on this form. We will use the information you
provide to obtain your earnings data or the earnings data of a deceased individual. Your
responses are voluntary. However, failure to provide us with the requested information
could prevent us from processing your request.
We rarely use the information you give us for any purpose other than providing the
earnings information you request. However, we may use the information for the efficient
administration of our programs. We may also disclose information to another person or
agency in accordance with approved routine uses, including but not limited to the
following:
1. To enable a third party or an agency to assist Social Security in establishing rights
to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office, General Services
Administration, the Department of Justice, and the Department of Treasury);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you give us in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local
government agencies. We use the information from these programs to establish or verify
a person’s eligibility for Federally-funded or administered benefit programs and for
repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses of the information you gave to us is available in our
Privacy Act System of Records Notice entitled, Earnings Recording and SelfEmployment Income System, 60-0059. Additional information about this and other
systems of records notices and our programs are available from our Internet website
at www.socialsecurity.gov or at your local Social Security Office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 about 2
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.