Form SSA-820-BK Work Activity Report (Self-Employment)

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

Date:
Claim Number:

-

-

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 the following self-employment income 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.
Self Employment

Form SSA-820-BK (09-2011) ef (09-2011)

Year

Yearly Income

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 (
)
. 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:

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.

Social Security Administration

Enclosures:
SSA Pub No. 05-10095
Pre-addressed Envelope

Form SSA-820-BK (09-2011) ef (09-2011)

Form Approved
OMB No. 0960-0598

SOCIAL SECURITY ADMINISTRATION

Work Activity Report - Self-Employment
Identification - To Be Completed by SSA
Claimant or Beneficiary's Own SSN

Name of Claimant or Beneficiary

-

Blind
Not Blind

-

Claim Number(s) & BIC

Please use this form to describe your work activity since (Insert alleged onset date, date DATE
of entitlement, or last determination date, as appropriate)

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 self-employment income since the DATE shown above in the Identification section? (check one)
NO. If you did not work but income was reported for you, go to Question 2.
YES. Go to QUESTION 3.

2. If you did not work but income was reported for you, complete the information below. When you are finished, go to
Question 9.
Payment For
Example: Income
after business
stopped

Name and Address of Payer

Amount or Estimate of Value

ABC Company
123 Any Street
Your Town, MD 54321

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

per

$

per

Date Worked
(MM/YYYY - MM/YYYY)

01/2000 - 02/2000

3. Please tell us about your work since the DATE in the Identification section.
Type of Self-Employment or Name of Business

Area Code and Telephone Number Area Code and Fax Number

Mailing Address

City

State

ZIP

What is the primary product or service?

Date Work Started (MM/YYYY) Date Work Ended (if ended) (MM/YYYY)

Still working

Average Number of Hours
Worked

Type of ownership arrangement? (Check one)
Sole Owner

Limited Liability Company (LLC)

Corporation

Partnership

Farm Landlord

Farm Tenant

Form SSA-820-BK (09-2011) ef (09-2011)
Destroy Prior Editions

Page 1

Other (Please explain)

Claim #:

-

-

4. In the space below, show each month you worked in your business, the net earnings, and if you worked 45 hours or more.
Date Worked
(MM/YYYY)

Net Earnings

Worked more than 45
hours per month?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Date Worked
(MM/YYYY)

Net Earnings

Worked more than 45
hours per month?

No
No
No
No
No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No

If you need more room for your answers, go to the Remarks section.

5. Please attach all of your self-employment tax returns (including Schedule C & SE) since the DATE shown in the
Identificiation section.
I have ENCLOSED my Tax Returns. Go to Question 6.
I DO NOT have Tax Returns. For any years that you DO NOT have tax returns, use the chart below to tell
us about your total annual gross and net self-employment income.
Year (YYYY)

Gross

Net

Year (YYYY)

Gross

Net

$

$

$

$

$

$

$

$

6. Has anyone besides yourself had management responsibilities for this business (i.e., a partner, employee, relative, or
helper) since the DATE shown in the Identification section?
NO. Go to Question 7.
YES. Complete the questions below

How many hours per month (on average) does or did the other person(s) spend
on management duties?
How many hours per month (on average) do or did you spend on management
duties?
Please tell us what duties you and the other person performed below.

Form SSA-820-BK (09-2011) ef (09-2011)

Page 2

Hours per month
Hours per month

Claim #:

-

-

7. Since the DATE shown in the Identification section did you make any changes in your work activity due to your
physical and/or mental condition(s)?
NO. Go to Question 8.
YES. Please describe your changes below. (Check all that apply below.)
Type of Change

Date (MM/YYYY)

Please Explain

Stopped working

My hours reduced from
to

Reduced my work hours

per

per
because

Changed to lighter or easier work

Other changes

8. Has any person or organization contributed to or paid for any business expenses or provided any free help, items, or
services related to your business since the DATE shown in the Identification section? (For example: rent, supplies,
inventory, purchase, repair of equipment, or an employee or helper that works for you for free.)
NO. Go to Question 9.

YES. Describe the expenses paid or items or services provided, their value of the
contribution, and who provided them below.

Form SSA-820-BK (09-2011) ef (09-2011)

Page 3

Claim #:

-

-

9. Do or did you 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. Go to the next section.
YES. 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

Cost

Date Paid
(MM/YYYY - MM/YYYY).

Example: Money spent for
medicines

$100 per day, week, month, or year

01/2009 - 02/2009

$

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-820-BK (09-2011) ef (09-2011)

Page 4

Claim #:

-

-

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.

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

Area Code and Telephone Number

Date

Mailing address

City

State

ZIP
-

If this statement is signed with a 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

Area Code and Telephone Number

Date

Mailing address

City

State

ZIP
-

2. Signature of Witness

Area Code and Telephone Number

Date

Mailing address

City

State

ZIP
-

Form SSA-820-BK (09-2011) ef (09-2011)

Page 5

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 to the 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.

Paperwork Reduction Act Statement
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 30
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. 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-820-BK (09-2011) ef (09-2011)

Page 6