Form SSA-821-BK Work Activity Report- Employee

Social Security Administration
Retirement, Survivors, and Disability Insurance
Important Information
FO Address
Date:
Claim Number:

Beneficiary name
Address
City St ZIP
We are writing to you because we need to know more about your work. Please tell us about your
work since ____ /_____/_______. We will use this information to decide if you can receive or
continue to receive disability benefits.
What You Need To Do
Please complete and return the completed form within 15 days to the address shown above. It is
important to fill out the form carefully and completely. Remember to sign and date the form. If
you do not return this form, we may contact your employer or make our determination based on the
evidence we have in our records.
Some Information To Help You Complete This Form
Our records show these employers and yearly earnings for you. This list may not be complete.
It may not show your work for this year or last year. You should add any additional work
information as you complete the form.
Employer Name

Year

Earnings

Form SSA-821-BK
(mm-yyyy)

If You Have Questions
If you have any questions, or need help completing the form:
 Visit us online at www.socialsecurity.gov. We can answer many of your general
questions online.
 Call us toll-free at 1-800-772-1213, or call your local field office at xxx-xxx-xxxx. If you
are deaf or hearing impaired, our TTY toll-free number is 1-800-325-0778. We can
answer most of your questions over the phone.
 Write or visit any Social Security office. The office that serves your area is located at:
Insert local FO address
If you live outside the United States, please contact any Social Security office or the nearest
United States Embassy, or consulate. If you live in the Philippines, you may contact the Veterans
Administration Regional Office, Social Security Division, 1131 Roxas Boulevard, Manila. You
may also write the Social Security Administration, P.O. Box 17775, Baltimore, Maryland,
21235-7775, USA.
If you do call or visit an office, please have this letter with you. It will help us answer your
questions. Also, if you plan to visit an office, please call ahead to make an appointment. This
will help us serve you more quickly.
Please read the enclosed pamphlet, “Working While Disabled ... How We Can Help.” It will tell
you more about why we need to know about your work, and will explain our rules about
working. This pamphlet is also available online at www.ssa.gov/pubs/10095.html.

District Manager

Enclosures:
Form(s): SSA-820-F4 or SSA- 821-BK
----------------------SSA Pub No. 05-10095
Pre-addressed Envelope

Form SSA-821-BK
(mm-yyyy)

Claim #

Social Security Administration

Form Approved
OMB No. 0960-0059

Work Activity Report - Employee
Identification - To Be Completed by SSA
Name of Claimant or Beneficiary

Claimant or Beneficiary’s Own SSN

Blind
Not Blind

Claim Number(s) & BIC
Please use this form to tell us about your work activity since (Insert alleged onset date, date of onset, date of entitlement, or
last determination date, as appropriate).

DATE

Information - To Be Completed By Person Applying For Or Receiving Benefits
Please answer each of the questions on this form with as many details as you can. This information will help us decide if you
should get or keep getting disability benefits.
If you need more room for your answers, go to the Remarks Section at the end of the form.
1. Have you had any employment income or wages since the DATE shown above in the Identification section? (check one)
NO. If you did not work but earnings were reported for you, go to Question 2.
YES. Go to Question 3.
2. If you did not work, other types of income may have been reported for you. Please complete the information below. We may ask you
for proof of this income. When you are finished, go to Question 7.
Type of Payment



Example

Name and Address of Payer
ABC Company
123 Any Street,
Your Town, MD 54321

Amount

$100 per day, week,
01/2000 - 02/2000
month, or year

Back Pay

$ _____per_______

Vacation Pay

$ _____per_______

Holiday Pay

$ _____per_______

Bonus or Commission

$ _____per_______

Royalties

$ _____per_______

Sick Pay

$ _____per_______

Disability Pay

$ _____per_______

Insurance Payment

$ _____per_______

Workers Compensation

$ _____per_______

Other (please explain)
$ _____per_______
Form SSA-821-BK (mm-yyyy)

1

Date Received
(MM/YYYY - MM/YYYY)

Claim #
3A. Please tell us about your work since the DATE shown in the Identification section, beginning with your most recent
employer. If you are not sure about this, ask your employer(s) to help you. Use the additional space provided in the Remarks section if
you need more room for your answer.
Current Or Most Recent Employer’s Name

Area Code and Telephone Number

Mailing Address

Area Code and Fax Number

City

State

ZIP

Job Title & Type of Work
Date Work Started

Date Work Ended (If ended)

(MM/YYYY)

(MM/YYYY)

Still working Rate of Pay

Hours Worked per Week

$ ________ per ___________

(on average)

Attach copies of all your pay stubs from this employer or ask this employer for a wage print-out showing gross monthly earnings since
the DATE shown in the Identification section.
I have ENCLOSED Pay Stubs or Gross Wage Print Outs.
I DO NOT have Pay Stubs or Gross Wage Print Outs. For any months that you DO NOT have pay stubs or a print-out, use the
chart below to tell us how much you earned (before deductions) in each month.
Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

$

$

$

$

$

$

$

$

$

$

$

$

3B. If you do not have any more employers, go to question 4.
Previous Employer’s Name

Area Code and Telephone Number
City

Mailing Address

Area Code and Fax Number
State

ZIP

Job Title & Type of Work
Date Work Started

Date Work Ended (If ended)

(MM/YYYY)

(MM/YYYY)

Hours Worked per Week

Still working Rate of Pay
$ ________ per ___________

(on average)

Attach copies of all your pay stubs from this employer or ask this employer for a wage print-out showing gross monthly earnings since
the DATE shown in the Identification section.
I have ENCLOSED Pay Stubs or Gross Wage Print Outs.
I DO NOT have Pay Stubs or Gross Wage Print Outs. For any months that you DO NOT have pay stubs or a print out, use the
chart below to tell us how much you earned (before deductions) in each month.
Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

$

$

$

$

$

$

$

$

$

$

$

$

Form SSA-821-BK (mm-yyyy)

2

Claim #
3C. If you do not have any more employers, go to question 4.
Previous Employer’s Name

Area Code and Telephone Number

Mailing Address

City

Area Code and Fax Number
State

ZIP

Job Title or Type of Work
Date Work Started
(MM/YYYY)

Date Work Ended (If ended)
(MM/YYYY)

Rate of Pay

Still working

$ ________ per ___________

Hours Worked per Week
(on average)

Attach copies of all your pay stubs from this employer or ask this employer for a wage print-out showing gross monthly earnings
since the DATE shown in the Identification section.
I have ENCLOSED Pay Stubs or Gross Wage Print Outs.
I DO NOT have Pay Stubs or Gross Wage Print Outs. For any months that you DO NOT have pay stubs or a print out,
use the chart below to tell us how much you earned (before deductions) in each month.

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

Date Earned
MM/YYYY

Amount

Amount

$

$

$

$

$

$

$

$

$

$

$

$

If you have more employers, go to the Remarks section.
4. Do or did you get any other payment(s) or benefit(s) from an employer in addition to the regular pay shown in Question 3?
NO. Go to Question 5.
YES. Please check all that apply below.
Sick Pay

Disability Pay

Vacation Pay

Tips

Bonus

Transportation

Car or Vehicle

Childcare

Meals

Room or Rent

Other (Please explain):
For each payment or item checked, tell us the employer who provided it, the amount or dollar value, and when it was received.

Payment or Item

Employer Name

Amount or Estimate of Value

Example:
Sick Pay

ABC Company

$100 per day, week,
01/2000-02/2000
month, or year
$ _________per___________
$ _________per___________
$ _________per___________

Form SSA-821-BK (mm-yyyy)

3

Date Received
(MM/YYYY - MM/YYYY)

Claim #
5. For any job(s) that you told us about in Question 3, have you worked under any special conditions listed below?

Yes

Special Condition

Employer Name

Had extra help, extra supervision or
a job coach
Worked irregular or fewer hours
than other workers
Given special equipment because
of my condition
Took more rest periods than other
workers
Given special transportation to and
from work
Had fewer or easier duties than
other workers
Allowed to produce less work than
other workers
Hired through special training or
therapy program
Given work that was suited to
my condition
Given special help getting ready
for work
Other (explain)

Other (explain)

None of the above apply. Go to Question 6A.

Form SSA-821-BK (mm-yyyy)

4

Date
(MM/YYYY to
MM/YYYY)

Please Describe

Claim #
6A. For any job that you told us about in Question 3, did you make any of the changes below since the DATE shown in the Identification
section. (Check all that apply).

Yes

Special Condition

Employer Name

Date
(MM/YYYY)

Reasons for Changes in Work Activity
My physical and/or mental condition(s).
Special conditions that helped me to work
were removed.
Other reasons. (Please explain in 6B).

Stopped working

My physical and/or mental condition(s).
Special conditions that helped me to work
were removed.

Reduced my
work hours

Other reasons. (Please explain in 6B).
My physical and/or mental condition(s).

Reduced my earnings

Special conditions that helped me to work
were removed.
Other reasons. (Please explain below 6B).
My physical and/or mental condition(s).

Changed to a lighter
or easier type of work

Special conditions that helped me to work
were removed
Other reasons. (Please explain below 6B).

NO, I did not make any changes since the date shown in the Identification section. Go to Question 7.

6B. Use this space to provide any additional information about your work changes.

Form SSA-821-BK (mm-yyyy)

5

Claim #
7. Do or did you have to spend any of your own money for items or services related to your physical and/or mental condition(s) that
you needed in order to work and for which you did not get reimbursed? (For example: medicines or co-pays, medical devices or
procedures, Braille equipment, special telephone or equipment, service animal, attendant care, modifications to a car used for work, or
other special transportation.) We may ask you for proof of payment.
NO, I did not spend any of my own money for items or services related to my physical and/or mental condition.
YES. Please tell us what you paid below. Do not show any expenses that have been or will be paid by an insurance company,
other organization, or other person.

Describe Item or Service
Example: Service animal

Cost
$100 per day, week,
month, or year

Date Paid
(MM/YYYY - MM/YYYY)
01/2000 - 02/2000

$______ per _______

$______ per _______
$______ per _______

$______ per _______
Remarks
Use this section to add any information you did not have space for in other parts of the form. Please show the number of the question
you are answering.

Form SSA-821-BK (mm-yyyy)

6

Claim #
Signature
I authorize any employer, agency, or other organization to disclose to the Social Security Administration or the State agency that may
determine or review my entitlement to disability benefits, any information about my physical and/or mental condition(s) or my work.
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. I understand that anyone who knowingly gives a false or
misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
sent to prison or may face other penalties, or both.
Signature of Claimant, Beneficiary, or Representative

Date

Mailing Address

City

Area Code and Telephone Number
State

ZIP

If this statement is signed by mark (e.g. X), two witnesses to the signing who know the person making the statement must sign
below, giving their full addresses and telephone numbers.
1. Signature of Witness
Mailing Address
2. Signature of Witness
Mailing Address

Date

Area Code and Telephone Number

City
Date

State

ZIP

Area Code and Telephone Number

City

State

ZIP

Privacy Act Statement
Collection and Use of Personal Information
Sections 223 and 1632 of the Social Security Act as amended [42 U.S.C. 423 and 1383a], authorize us to collect this information. The information you
provide will allow us to determine your eligibility for benefits. Your response is voluntary. However, your failure to provide all or part of the
requested information could prevent us from making an accurate and timely decision on your claim and could result in the loss of benefits.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above. However, we may use it for the
administration and integrity of Social Security programs. We may also disclose information to another person or to another agency 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 and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office,
General Services Administration, National Archives Records Administration, and the Department of Veterans 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 investigative 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
agencies can be used to establish or verify a person’s eligibility for Federally-funded or 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 our System of Records Notice entitled, Earnings Recording and Self-Employment
Income System, 60-0059. The notice, additional information regarding this form, and information regarding our system and programs, are available
on-line at www.socialsecurity.gov or at any local Social Security office.

Form SSA-821-BK (mm-yyyy)

7

PAPERWORK REDUCTION ACT
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 45 minutes to read the
instructions, gather the necessary facts, and answer the questions. SEND THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is
listed under U.S. Government agencies in your telephone directory or you may
call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send
comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address,
not the completed form.

Form SSA-821-BK (mm-yyyy)

8