Current SSA-1398

Form Approved
OMB NO. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Self-Employment Income (SEI) Form
Beneficiary Quarterly Report
Self-Employment
Beneficiary Name: ___________________

SSN: _______________________

Calendar Quarter:______________________

Month ___________

Month ___________

Month ___________

Gross Income
Gross Expenses
Net SelfEmployment Income
I was actively involved in the operation of my business during the following months:




______________
______________
______________

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.
Beneficiary Signature __________________________

Date ___________________

Address _______________________________
________________________________
________________________________

Phone __________________
Email __________________

____________________________________________________________________________________
Form SSA-1398 (xx-xxxx)

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Privacy Act Statement
Collection and Use of Personal Information

Section 1148, of the Social Security Act, as amended, authorizes us to collect this information. The
information is needed to permit the Social Security Administration (SSA) to verify eligibility for
payment. The information you furnish on this form is voluntary. However, failure to provide all or part
of the information requested on this form could prevent receipt of payment.
We rarely use the information you supply for any purpose other than verifying eligibility for payment.
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: (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
and Department of Veteran Affairs); (3) to make determinations for eligibility in similar health and
income maintenance programs at the Federal, State, and local level; (4) to State agencies or Employment
Networks having an approved business arrangement with SSA to perform vocational rehabilitation
services for disability beneficiaries and recipients; and (5) 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 and 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 Systems of Record Notices 60-0295
and 60-0300. The notices, additional information regarding this form, and information regarding our
programs and systems, are available on-line at www.socialsecurity.gov or at your local Social Security
office.

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 control number.
5 minutes to read the instructions, gather the facts, and answer the
We estimate that it will take about XX
questions. SEND THE COMPLETED FORM TO MAXIMUS TICKET TO WORK, PO BOX
1433, ALEXANDRIA, VA 22313, OR FAX TO 703-683-3289. 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-1398 (xx-xxxx)
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