Current SSA-581

Form Approved
OMB No. 0960-0602

Social Security Administration

Authorization to Obtain Earnings Data from the
Social Security Administration
Mail
completed
form to:

Requesting
organization:

Social Security Administration
Division Business Services
PO Box 33011
Baltimore, MD 21290-3011

RA PENF 8929
Southern California IBEW-NECA
Pension Fund
6023 Garfield Ave
City of Commerce, CA 90040

Number Holder's Information
First Name:

Middle Initial:

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:

--

--

through

Month

Year

Month

--

through

Month

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

--

--

Relationship (if other than number holder)

Printed Name (if other than

Natural or adoptive parent

number holder)

Address

Legal Guardian

State

Other (specify) ______________

ZIP Code

City

Phone Number

Requesting Organization's Information
Date

Signature of Organization Official
Phone Number
FOR SSA USE ONLY

Fax Number
1

Form SSA-581-OP159 (03-2013)

2

3

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IMPORTANT INFORMATION
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 Self-Employment 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.

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-OP159 (03-2013)

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