Information Collection

Work Activity Report (Self-Employed Person)

IC 9580 under ICR 201610-0960-006 · OMB 0960-0598.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0598 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-820-BK Work Activity Report (Self-Employed Person)	Form
SSA-820-BK - Revised PA Statement.pdf www.socialsecurity.gov	Other-Revised Privacy Act Statement
SSA-820-BK Work Activity Report (Self-Employment) SSA-820-BK.pdf www.socialsecurity.gov	Form
SSA-820-BK - Current Version.pdf Current SSA-820-BK	IC Document

IC Title:

Work Activity Report (Self-Employed Person)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1584-.1593 20 CFR 404.1571-1576 20 CFR 416.971-.976 20 CFR 404.1520(b)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-820-BK	Work Activity Report (Self-Employment)	SSA-820-BK.pdf	www.socialsecurity.gov	Yes	No	Fillable Printable
Other-Revised Privacy Act Statement			SSA-820-BK - Revised PA Statement.pdf	www.socialsecurity.gov	No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	100,000	50,000	50,000
Annual IC Time Burden (Hours)	50,000	25,000	25,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-820-BK	SSA-820-BK - Current Version.pdf	03/23/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.