When you are applying for social security disability benefits, it is important to make sure that you submit all of the required information. One document that you will need to provide is Form Ssa 581 Op65. This form asks a number of questions about your medical history and current condition. In order to complete the form accurately, it is important to understand what each question means. In this blog post, we will explain some of the key concepts covered on Form Ssa 581 Op65. Please keep in mind that this information is not intended to provide legal advice. If you have specific questions about your eligibility for disability benefits, you should speak with an experienced attorney.
| Question | Answer |
|---|---|
| Form Name | Form Ssa 581 Op65 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | authorizes, ssa 581 op 59, STE, SSN |
Social Security Administration |
Form Approved |
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OMB No. |
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Authorization to Obtain Earnings Data from the
Social Security Administration
Social Security Administration |
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completed |
PO Box 33011 |
form to: |
Baltimore, MD |
Requesting |
SSA Job No 8279 Index 1 |
organization: |
SHEET METAL WORKERS |
|
NATIONAL PENSION FUND |
|
8403 BLVD, STE 300 |
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FAIRFAX, VA |
Number Holder's Information
First Name:
Last Name:
SSN:
Date of Birth:
Middle Initial:
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Date of Death: |
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Month |
Day |
Year |
Month |
Day |
Year |
Other First, Middle Initial, and Last Name Used to Report Earnings:
Year(s) |
Y |
Y |
Y |
Y |
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Requested: |
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Y |
Y |
Y |
Y |
through
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
Printed Name (if other than |
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Relationship (if other than number holder) |
number holder) |
|
Spouse |
Address |
State |
Legal Representative |
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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)
Signature of Organization Official
Date
Phone Number
Fax Number
FOR SSA USE ONLY
1
2
3
4
Form |
Page 1 |
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
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
Form |
Page 2 |