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
Social Security Administration
Requesting
SSA Job No. 8### Index 01
completed
PO Box 33011
Organization:
ABC World Pension Fund
form to:
Baltimore, MD 21290-3011
2800 Jackson Street
Removed "Division of Business Services"
Imaginary, HH 12345-1234

Revised highlighted
language from "RA
PENF 09 8XXX"

Number Holder’s Information

*09828201210760000*

Middle Initial:

First Name:
Last Name:
SSN:

--

Date of Birth:

--

-Month

--

Date of Death:

-Day

Year

--

Month

Day

Year

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

through

Year(s)
Requested:

Y

Y

Y

Removed months

Y

Revised highlighted

Y

Y

Y

Y

from this section

through

language from

Y

"Period(s)"

Y

Y

Y

Y

Y

Y

Y

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
M

YYY" to the
Date section

-

M

Added the
"MM-DD-

D

D

Y

Y

Y

Y

Relationship (if other than number holder)

Printed name (if other than number holder)
Address

State

Spouse

Revised language

Legal Representative

from "Natural or

Other (specify)

City

ZIP Code

Phone Number

Adoptive Parent"
to "Spouse"; &
from "Guardian"
to

Requesting Organization’s Information
SSA must receive this form within 60 days from the date signed by the Number Holder (or Authorized Representative).

Signature of Organization Official

Date

"Representative"
Added the
highlighted
language.

Phone Number
FOR SSA USE ONLY

Fax Number

1

Form SSA-581-OP### (##-2014)
Destroy Prior Editions

2

3

4
Page 1

*018###09123456789*

IMPORTANT INFORMATION
Privacy Act Statement
Collection and Use of Personal Information

Revised PRA
language.

Section 205(c)(2)(A) of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to obtain earnings data.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to produce an itemized
statement of earnings. However, we may use the information for the administration of our
programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0059, entitled, Earnings Recording
and Self-Employment Income System. Additional information about this and other system of
records notices and our programs is available online at www.socialsecurity.gov or at your local
Social Security office.
We may share the information you provide to other health agencies through 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.
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.
Form SSA-581-OP### (##-2014)