Revision to the Collection Instrument
We are making revisions to clarify the language, remove questions, and streamline the form to make it easier for respondents to use. We are also revising our procedures to eliminate unnecessary development in certain self-employment cases. We anticipate these actions will decrease the burden hours for this form.
The last time we submitted this collection, we reported approximately 100,000 respondents take 30 minutes each to complete form SSA-820-F4 each year for a total estimated burden of 50,000 hours. Based on our change in procedure, we estimate only half the respondents will take the entire 30 minutes to complete the SSA-820-F4, while the other half will have a reduced burden of 15 minutes to complete the form. The chart below shows the revised burden estimates:
Form Number |
Number of Respondents |
Frequency of Response |
Average Burden per Response (minutes) |
Total Annual Burden (hours) |
SSA-820-BK |
50,000 |
1 |
15 |
12,500 |
SSA-820-BK |
50,000 |
1 |
30 |
25,000 |
Totals |
100,000 |
|
|
37,500 |
The revisions to the collection instrument are as follows:
Change 1: We are adding a cover letter.
Justification 1: We added the cover letter to explain the purpose of the form and provide contact information in the event that the beneficiary needs assistance. By making the cover letter part of the form, we can ensure that the cover letter is included each time we send the form.
Change 2: We added the claim number to the top of each page.
Justification 2: The claim number on each page will help with labeling on paper forms if the pages come apart. SSA staff requested this change.
Change 3: We added a heading that says “Identification-To Be Completed by SSA” and darkened the header.
Justification 3: The darkened headers will visually distinguish the headers from the rest of the page. The header provides information on the contents of the section.
Change 4: We changed the title of the first block from “Name of Disabled Person” to “Name of Claimant or Beneficiary.”
Justification 4: We made this change for consistency between this form and the SSA‑821‑BK.
Change 5: Changed title of the SSN block from “Social Security Number” to “Claimant or Beneficiary’s own SSN.”
Justification 5: Changed to provide the SSA users with specific instructions regarding which SSN to provide. In some instances, the claim number is not the beneficiary’s own SSN.
Change 6: Changed the title of the block from “Name of W/E (if other than disabled person)” and “Social Security Number” to “Claim number(s)” and “BIC.”
Justification 6: We do not need the name of the wage earner. We need Claim number and BIC, and SSA users are familiar with this terminology.
Change 7: Moved Paperwork and Privacy Act Notice language to the end of the form and updated the language.
Justification 7: Updated language provided by OGC. Moving the language to the end of the form conforms to SSA standards on other forms.
Change 8: Changed language from “date disability began or, if later, date of prior investigation” to “alleged onset date, date of onset, date of entitlement, or last determination date as appropriate.”
Justification 8: SSA users are familiar with this terminology, and these instructions provide specific information on the date to use.
Change 9: Shaded the date box.
Justification 9: Provides a visual highlight for an important date that we refer to throughout the rest of the form.
Change 10: We added a heading that says “Information-To Be Completed by Person Applying For Or Receiving Benefits” and darkened the header.
Justification 10: The darkened headers will visually distinguish the headers from the rest of the page. The new header provides information on the contents of the section, and shows where the beneficiary should begin.
Change 11:
Replaced the heading “Answer Each Question As Fully
As Possible,” with the following new language: “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” and
put them in bold font. Added information under Information-To Be
Completed by Person Applying For Or Receiving Benefits section.”
Justification 11: Instructions encourage beneficiaries to provide as much information as possible, and it provides information on why we need this, and what to do if they need more room. Bold font visually distinguishes these important general instructions.
Change 12: Make the questions numbers bold.
Justification 12: Provides a visual distinction for each question.
Change 13: Moved question 1 (Date) to top of the form, and added a new question 1.
In question 1 we are now asking for information about income reported as self-employment, which may not represent self-employment work activity. Added yes or no check boxes, capitalized the yes and no, and put them in bold font. For each check box, we provided instructions on which question to go to next.
Justification 13: This is consistent with question 1 on SSA-821-BK, Work Activity Report-Employee. Many beneficiaries must complete both forms.
Change 14: Moved question 2 to question 3, and added new information for question 2, to capture information about payments, which may not reflect self-employment work activity, and instructions to go to question 7 if the beneficiary did not work.
Justification 14: This is consistent with question 2 on the SSA-821-BK Work Activity Report-Employee. Many beneficiaries must complete both forms. The instructions will help users understand the directions.
Change 15: Added a chart for the beneficiary to complete, and an example to question 2.
Justification 15: The chart provides structure for the response, and the example provides an illustration of what kind of information we need.
Change 16: Added instructions that asked the beneficiary to please tell us about their work.
Justification 16: Provides clear instructions to the user and addresses SSA initiative to be more polite in our communications.
Change 17: Merged old question 2 and 3 into current question 3.
Justification 17: This change will assist users to understand the questions. All information in new question 3 is for the same period of self-employment.
Change 18: Added a request for a phone number and fax number.
Justification 18: SSA users requested this change. This will make contact easier.
Change 19: Added a request for the date work started and stopped.
Justification 19: SSA needs this information to make a work determination. SSA users requested this change.
Change 20: Moved old question 3B to new question 4 and updated the chart. Also changed the question about hours worked from 40 hours per month to 45 hours per month.
Justification 20: The new chart will assist users to provide the needed monthly information, and provides room for a greater number of months of earnings. SSA users requested this change. Changing the question about hours worked reflects changes in trial work period and substantial gainful activity guidelines since the last time the form was revised.
Change 21: Added question 5 to request verification of yearly self-employment income (tax records), or a chart for users to provide yearly income if they cannot provide tax returns.
Justification 21: We also need information on yearly self-employment income. We make substantial gainful activity determinations based on average monthly earnings. Self-employment income may fluctuate throughout the year and we may need annual totals to make a work determination.
Change 22: Combined old question 4 and 6 to create new question 6. Revised the wording of the question to capture more specific information about management responsibilities.
Justification 22: We use information on management responsibilities to make substantial gainful activity determinations on self-employment income.
Change 23: Reworded old question 5 to create new question 7. Revised the wording of the question to capture more specific information about changes in work activity due to disability. We also provided a chart with examples of some of the specific information we need, and provided information in the “reduced my work hours” block to get specific information hours worked.
Justification 23: We need this information to help us determine when self-employment work fell below the substantial gainful activity level. We also use this information to help us determine if self-employment work activity may have been an unsuccessful work attempt.
Change 24: Combined old questions 7, 9, and question 8A to create new question 8. Revised the wording of the question to capture more specific information about unpaid help and un-incurred business expenses. We also added checkboxes for yes and no answers with instructions.
Justification 24: We deduct the value of any un-incurred business expenses when we determine countable income from self-employment to make substantial gainful activity determinations. We also consider the value of any unpaid help. The revised wording and instructions will help users understand what information we need.
Change 25: Revised old question 8B to create new question 9. Revised the wording of the question to clarify what expenses we need to know about, and added yes and no checkboxes with instructions. We also added a statement that we may need proof of these expenses. We also added a chart with an example.
Justification 25: We deduct impairment related work expenses when we determine countable income from self-employment. We must have proof of the expense to deduct it, and we must know when it was paid. However, we will only request proof of the expense if it is material to the determination.
Change 26: Removed the number 10 from question 10 and added a header titled Remarks. We also darkened the header.
Justification 26: We direct users to use the remarks section to provide more information for any question. The darkened header will visually distinguish the headers from the rest of the page and help users find it.
Change 27: Deleted question 11.
Justification 27: We no longer need this information.
Change 28: Added the Signature Section to the top of the page, and made bold. We did not change the content of the question.
Justification 28: We moved this question into its own section for organizational purposes.
Change 29: We are deleting page 4, “FOR SSA USE ONLY-DO NOT WRITE ON THIS PAGE.”
Justification 29: We created a new SGA determination form, the SSA-823, which will capture this information.
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |