Division of Coal Mine Workers' Compensation (DCMWC)

Two (2) copies of Form SSA-581 are required. By signing these forms, you are authorizing the Division of Coal Mine Workers' Compensation (DCMWC) to obtain your earnings records from the Social Security Administration (SSA), which will assist in verifying all coal mine-related employment.

Sending 2 forms is necessary because of how SSA verifies your employment history during different time periods. Please leave the "Year(s) Requested" fields blank, but complete all of the fields with your demographic information, then sign and date the forms.

Please sign and date the forms and return two copies of the SSA-581 forms to DCMWC at:

U.S. Department of Labor OWCP/DCMWC
P.O. Box 8307
London, KY 40742-8307

Please do not send completed forms directly to SSA at the Maryland address on the top left of Form SSA-581. DCMWC will send the forms to SSA once the forms are received at the above address. Thank you for your cooperation in signing, dating and returning both forms.