Information Collection

SSA-820 and SSA-821

IC 195231 under ICR 201011-0960-005 · OMB 0960-0189.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0189 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-820-F4 SSA-820 and SSA-821	Form
SSA-820-F4 Work Activity Report (Self-Employed Person) SSA-820 Final.pdf	Form
SSA-821-BK Work Activity Report-Employee ssa821bk.pdf	Form
ssa820.pdf SSA-820-F4	IC Document

IC Title:

SSA-820 and SSA-821

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-820-F4	Work Activity Report (Self-Employed Person)	SSA-820 Final.pdf		No		Paper Only
Form	SSA-821-BK	Work Activity Report-Employee	ssa821bk.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-820-F4	ssa820.pdf	03/17/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.