________________________市________________________区________________________社会保险管理中心：
本人________________________________________________________身份证号码________________________________________________________需将在________________________市缴纳的社会保险金________________________养老/医疗________________________转出________________________市，因故不能亲自前去贵中心办理，现委托________________________________________身份证号码________________________________________________________________代为办理转出手续。
本人________________________：________________________________________
本人户籍类型：城镇□农村□
本人户籍地邮编：________________________________________________________________
委托人：________________________签字按指印________________________
受委托人：________________________签字按指印________________________