Form SSA-766 Statement of Self-Employment Income

Social Security Administration

Form Approved
OMB NO. 0960-0046

TOE 320

STATEMENT OF SELF-EMPLOYMENT INCOME

PRIVACY ACTIPAPERWORK ACT NOTICE: Your response to this request is voluntary; however. failure to provide all or any part of the information requested may
affect the final decision on your claim. The information requested on this form is authorized by sections 404.101 and 404,1 09(aHc) of the Social Security
Regulations. The information you furnish will enable the Social Security Administration to determine whether self-employment income for the current taxable year
may be used in determining your eligibility for Social Security benefits. Information you furnish on this form may be disclosed by the Social Security Administration
to another person or governmental agency only with respect to Social Security programs and to comply with Federal laws requiring the exchange of information
between the Social Security Administration and another agency.
This information collection meets the clearance requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 5 minutes
to read the instructions, gather the necessary facts, and answer the questions.

See below for revised Privacy Act and
Paperwork Reduction Act Statements.

1. NAME OF SELF-EMPlOYED PERSON

2. SOCIAL SECURITY NUMBER

3. NAME AND ADDRESS OF TRADE OR BUSINESS

4, NATURE OF TRADE OR BUSINESS

5. Net earnings from self-employment for the period from:

to

In answering items numbered 6, 7, and 8 follow the same general rules used for computing your net earnings
from self-employment on your Federal income tax return. (This is only an estimate of self-employment income and
does not relieve the seff-employed person from filing the proper tax return at the end of the taxable year.)

6. The gross income of this business during the above period was not less than

$

7. The total business expenses during the same period were not more than

$

8. The net earnings were not less than (item 6 less item 7)

$

9. If your actual net earnings at the end of your taxable year are less than $400. will
you report your self-employment income under the optional method?

DYes

DNo

ANSWER 10 IN ALL CASES

10. Give the basis for your knowledge of the amounts shown above:

I know that anyone who makes or causes to be made a false statement or representation of material fact in an
application or for use in determining a right to payment under the Social Security Act commits a crime punishable
under Federal law by fine, imprisonment or both. I affirm that all information I have given in this document is true.
DATE

FOAM

SIGNATURE OF SelF-EMPLOYED PERSON OR WHERE SELF-EMPLOYED PERSON IS DECEASED OR INCOMPETENT.
OF PERSON HAVING KNOWLEDGE OF THE FACTS.

SSA-766 15·19831

EF (9-20001

·U-S. Government Printing Office: 2001-491-689160020

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 5
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.

PRIVACY ACT NOTICE
Sections 404.101 and 404.109(a)(c) as amended in the Social Security Regulations,
authorizes us to collect this information. The information you provide will help us to
determine your potential eligibility for benefit payments and to help us to decide if
additional information is needed. Your response is voluntary. However, failure to
provide this requested information may prevent an accurate and timely decision on any
claim filed, or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for
determining entitlement to benefit payments. However, we may disclose the information
provided on this form in accordance with approved routine uses, which include but are
not limited to the following.
1) To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits or coverage.
2) To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veteran’s Affairs);
3) To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4) To facilitate statistical research, audit or investigate activities necessary to assure the
integrity of Social Security programs
We may also use the information you provide in Computer Matching programs.
Matching programs compare our records with records kept by other Federal, State, or
local government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally-funded and administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in System of Record
Notice 60-0059.
The notice, additional information regarding this form, and information regarding our
programs and systems are available on-line at www.socialsecurity.gov or at any local
Social Security office.