Form SSA-820-F4 Work Activity Report (Self-Employed Person)

Form Approved
OMB No. 0960-0598

SOCIAL SECURITY ADMINISTRATION

WORK ACTIVITY REPORT (Self-Employed Person)
Name of disabled person

Blind
Not Blind

Social Security Number

-

-

Social Security Number

Name of W/E (If other than disabled person)

-

-

PAPERWORK/PRIVACY ACT NOTICE
The information requested on this form is authorized by Section 223 and Section 1632 of the Social Security Act. The information provided will be used in making a decision on
your claim. While completion of this form is voluntary, failure to provide all or part of the requested information could prevent an accurate and timely decision on your claim and
could result in the loss of benefits. Information you furnish on this form may be disclosed by the Social Security Administration to another person or governmental agency only
with respect to Social Security programs and to comply with Federal law requiring the exchange of information between Social Security and another agency.
We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State or local
government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do
this even if you do not agree to it. Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices.
If you want to learn more about this, contact any Social Security Office.

See below for
revised Paperwork
Reduction Act and
Privacy Act
PAPERWORK REDUCTION ACT: 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 aStatment.
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.

Please use this form to describe your work activity since (Date disability began or, if later,
date of prior investigation)

1. Date (to be entered by SSA)

ANSWER EACH QUESTION AS FULLY AS POSSIBLE
A. List name and address of business (include ZIP code)

2.
C. Briefly indicate the primary product or service

B. Please Check if
Farm

Non-Farm

A. Describe the business in terms of arrangement and /or ownership (Check one)
Sole Owner

Partnership

Farm Tenant

Farm Landlord

B. Give your monthly self-employment income since the above date (average if not sure)
Month

Year

Gross

Net

Month

Year

Gross

Net

Month

Year

Gross

Net

Month

Year

Gross

Net

Month

Year

Gross

Net

Month

Year

Gross

Net

3.

C. List any months in which you earned more than
$200.00 or worked more than 40 hours in your
business since the date shown in item 1.
A. Describe (briefly) what you did in the business in terms of management decisions, responsibilities, hours, production
and services before your illness or injury.

4.
B. Was this business your sole livelihood
YES
NO
prior to your illness or injury?
Please describe your present work activities and any changes in your business because of your illness or injury.
Explain such things as reduced hours of business, lower volume, fewer acres under cultivation or other. (If you use
extra help, write "extra help" here and provide the details when you get to item 9).

5.

Form SSA-820-F4 (2-1991) ef (12-2008)

1

If you need more space
for any answer, use Page 3.

Do (did) you make management decisions after your illness or injury?

YES

NO

(If "yes," describe the kinds of decisions made, the time spent making them and any changes that have taken place).

6.

A. If you began your business after you were injured or became ill, did you receive any special assistance
from an agency or other source in setting up your business?
YES

7.

B. Does this assistance continue or have additional special services been supplied?
(If "yes," please describe)

YES

NO
NO

A. What is the value of any normal business expense which you do (did) not pay including that which is furnished or
paid for by another person or organization (such as free space or utilities)? Why were such items supplied to you for
free and by whom were they furnished?

8. B.

Describe any special expenses related to your illness or injury that you paid which are necessary for you to work (for
example, attendant care, medical devices, equipment, prostheses, or similar items or services).

DESCRIBE ANY ADDITIONAL HELP YOU NEED (NEEDED) IN PERFORMING YOUR USUAL DUTIES BECAUSE OF
YOUR ILLNESS OR INJURY.
A. Number of assistants
B. Time they devoted to helping you C. What do (did) they do?
E. If paid, how much?
D. Are/were assistants (check one)
PAID
UNPAID
F. Is (are) assistant(s) related to you? (check one) G. If yes, what is the relationship?
YES
NO
H. Why was the additional help needed?

9.

Form SSA-820-F4 (2-1991) ef (12-2008)

2

If you need more space
for any answer, use Page 3.

Use this section for additional space to answer any previous questions and to give any additional information you think
will be helpful. Please refer to the previous questions by number, such as 4A or 4B or 5.

10.

If more space is needed, use an extra sheet.
Check the appropriate block below:

11.

I am not receiving Social Security disability benefits and/or Supplemental Security Income (SSI).
I am receiving Social Security disability benefits and/or Supplemental Security Income (SSI), and I understand
that the information provided above may result in my benefits being stopped. I have been given the opportunity
to submit any evidence I wanted and to make any statements concerning my claim.

PLEASE READ THE FOLLOWING STATEMENT, THEN SIGN, DATE AND PROVIDE ADDRESS AND TELEPHONE NUMBER.

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

Date

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

Telephone (Include area
code)

City

State

County

ZIP Code
-

Form SSA-820-F4 (2-1991) ef (12-2008)

3

SSA USE ONLY
A. Contact made:
(check one)

IN PERSON

BY MAIL

BY TELEPHONE

B. Completed by:
(check one)

CLAIMANT

SSA REPRESENTATIVE

OTHER

12. C.

13.

If "Other" show

Name:

Address (include ZIP code)

Phone Number (include area code)

Relationship

Interviewer/reviewer check list ("Yes" answers should be developed in accordance with DI 13010ff. Rationalize "Yes"
or "No" answers below except when it is necessary to complete the SSA-831-U3 and SSA-833-U3). Check all that
apply:
A. Unpaid business expenses
(Rent, utilities, etc.)

Yes

No

B. Impairment-related work expenses

Yes

No

C. Unpaid help, or business sponsored by an agency

Yes

No

D. Unsuccessful work attempt (CDI - no medical issue - DO
jurisdiction for a final determination)

Yes

No

E. Unsuccessful work attempt
(DO recommendation only - DDS jurisdiction for a final determination.)

Yes

No

F. Substantial gainful activity

Yes

No

Note: If work continues and is determined to be substantial gainful activity and no medical issue exists, prepare the
appropriate final determination (SSA-831-U3 or SSA-833-U3) rationalizing the work issue. Keep in mind that
preparation of the SSA-831-U3 or the SSA-833-U3 would not be appropriate if there is a possibility of a closed
period of disability, a trial work period or an unsuccessful work attempt.
Rationale:

14. Remarks

15. Signature of SSA interviewer or reviewer

Form SSA-820-F4 (2-1991) ef (12-2008)

DO code

Title

4

Date

Work Activity Report (Self-Employed Person), Form, SSA-820-F4
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 with 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.

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 control number. We estimate that it will take about 30
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.