Form Ssa-581-Op65 - Authorization To Obtain Earnings Data From The Social Security Administration

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Form Approved
Social Security Administration
OMB No. 0960-0602
Authorization to Obtain Earnings Data from the
Social Security Administration
Mail
Social Security Administration
Requesting
SSA Job No 8279 Index 1
completed
PO Box 33011
organization:
SHEET METAL WORKERS
form to:
Baltimore, MD 21290-3011
NATIONAL PENSION FUND
8403 BLVD, STE 300
FAIRFAX, VA 22031-4601
Number Holder's Information
First Name:
Middle Initial:
Last Name:
--
--
SSN:
--
--
--
Date of Birth:
--
Date of Death:
Month
Day
Year
Month
Day
Year
Other First,
Middle Initial,
and Last Name
Used to Report
Earnings:
through
Year(s)
Y
Y
Y
Y
Y
Y
Y
Y
Requested:
through
Y
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 M
D D
Y Y Y Y
Relationship
Printed Name
(if other than number holder)
(if other than
Spouse
number holder)
Legal Representative
Address
State
Other (specify)
City
ZIP Code
Phone Number
Requesting Organization's Information
SSA must receive this form within 60 days from the date signed by the Number Holder (or Authorized Representative)
Date
Signature of Organization Official
Phone Number
Fax Number
FOR SSA USE ONLY
1
2
3
4
Form SSA-581-OP65 (11-2014)
Page 1

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