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
PO Box 33011
Baltimore, MD 21290-3011

Requesting
organization:

SSA Job No 8000 Index 01
UNUMPROVIDENT CORPORATION
1 FOUNTAIN SQ 15C10
CHATTANOOGA TN 37402

Number Holder's Information
First Name:

Middle Initial:

Last Name:

--

--

SSN:

--

--

Date of Birth:

Day

Month

Year

--

--

Date of Death:
Month

Day

Year

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

Year(s)
Requested:

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

through
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 (if other than number holder)

Printed Name (if other than

Spouse

number holder)

Address

Legal Representative

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
FOR SSA USE ONLY

Fax Number
1

Form SSA-581-OP1 (11-2014)

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IMPORTANT INFORMATION
Privacy Act Statement
Collection and Use of Personal Information
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-OP1 (11-2014)

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