Form SSA-821-BK Work Activity Report- Employee

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

Date:
Claim Number:

-

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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 eed 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

Form SSA-821-BK (06-2011) ef (06-2011)

Year

Earnings

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-821-BK (06-2011) ef (06-2011)

Form Approved
OMB No. 0960-0059

SOCIAL SECURITY ADMINISTRATION

Work Activity Report - Employee
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 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 income was 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

Amount

Date Worked
(MM/YYYY - MM/YYYY)

ABC Company
123 Any Street
Your Town, MD 54321

$100 per day, week, month, or
year

01/2000 - 02/2000

Back Pay

$

per

Vacation Pay

$

per

Holiday Pay

$

per

Bonus or Commission

$

Royalties

$

Sick Pay

$

Disability Pay

$

Insurance Payment

$

Workers Comp

$

per
per
per
per
per
per

Other (Please explain)
$

Form SSA-821-BK (06-2011) ef (06-2011)
Destroy Prior Editions

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Claim #:

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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.
Area Code and Telephone Number Area Code and Fax Number
Current or Most Recent Employer's Name
Mailing address

State

City

ZIP Code

Job Title and Type of Work

Date Work Started
(MM/YYYY)

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

Still working Rate of Pay
$

Hours Worked per
Week (on average)

per

Attach copies of all your pay stubs from this employer or ask the 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.
Amount

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

$

$

$

$

$

$

$

$

$

$

$

$

3B. If you do not have any more employers, go to Question 4.
Area Code and Telephone Number

Previous Employer's Name
Mailing address

Area Code and Fax Number

State

City

ZIP Code

Job Title and Type of Work

Date Work Started
(MM/YYYY)

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

Still working Rate of Pay
$

Hours Worked per
Week (on average)

per

Attach copies of all your pay stubs from this employer or ask the 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

Amount

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

$

$

$

$

$

$

$

$

$

$

$

$

Form SSA-821-BK (06-2011) ef (06-2011)

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Claim #:

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3C. If you do not have any more employers, go to Question 4.
Area Code and Telephone Number

Previous Employer's Name
Mailing address

Area Code and Fax Number

State

City

ZIP Code

Job Title and Type of Work

Date Work Started
(MM/YYYY)

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

Still working Rate of Pay
$

Hours Worked per
Week (on average)

per

Attach copies of all your pay stubs from this employer or ask the 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.
Amount

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

$

$

$

$

$

$

$

$

$

$

$

$

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):

Payment or Item

Employer Name

Amount or Estimate of Value

Date Received
(MM/YYYY - MM/YYYY)

Example: Sick Pay

ABC Company

$100 per day, week, month, or
year

01/2000 - 02/2000

Form SSA-821-BK (06-2011) ef (06-2011)

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$

per

$

per

$

per

Claim #:

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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 the above apply. Go to Question 6A.

Form SSA-821-BK (06-2011) ef (06-2011)

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Date
(MM/YYYY to
MM/YYYY)

Please Describe

Claim #:

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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)

Stopped working

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

Reduced my
work hours

My physical and/or mental condition(s)

Reduced my
earnings

Special conditions that allowed me to
work were removed.

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

Changed to a
lighter or easier
type of work

Special conditions that allowed me to
work were removed.

Other reasons. (please explain in 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 (06-2011) ef (06-2011)

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Claim #:

- 7. 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. 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

Cost

Date Paid
(MM/YYYY - MM/YYYY)

Example: Service animal

$100 per day, week, month, or year

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 (06-2011) ef (06-2011)

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Claim #:

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-

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
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 (Number and Street, Apt. no., P.O. Box, or Rural Route.)

City

State

ZIP Code
-

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 (Number and Street, Apt. no., P.O. Box, or Rural Route.)

City

State

ZIP Code
-

2. Signature of Witness

Area Code and Telephone
Number
(
)
-

Date

Mailing address (Number and Street, Apt. no., P.O. Box, or Rural Route.)

City

State

ZIP Code
-

Form SSA-821-BK (06-2011) ef (06-2011)

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act, as amended, authorize us to collect this
information. The information on this form is needed by Social Security to make a decision on the named
claimant's claim. While giving us the information on this form is voluntary, failure to provide all or part of the
requested information could prevent an accurate or timely decision on the named claimant's claim. We
generally use the information you supply for the purpose of making decisions regarding claims. 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 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 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 programs 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 Record and Self-Employment Income System, 60-0059. The notice, additional in formation
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
See Revised PRA
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 (06-2011) ef (06-2011)

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SSA will insert the following revised PRA Statement 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 (OMB) control number. The OMB control number for this
collection is 0960-0059. We estimate that it will take between 30 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.