SSA-821-BK Work Activity Report-Employee

Social Security Administration
Retirement, Survivors, and Disability Insurance
Important Information

•

Date:
Claim Number:

- -

Phone:

We are writing to you because we need to know more about your work.

The enclosed pamphlet, "Working While Disabled ... How Social Security Can Help",
will tell you more about why we need to know about your work.
What You Need To Do
The enclosed form asks for facts we need to know. Please sign, date, and return the
completed form within 15 days. We have enclosed an envelope for you to use.
If You Have Any Questions
If you have any questions, please let us know. You may also call, write, or visit any
Social Security office. If you do contact an office, please have this letter with you. It will
help us answer your questions.

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

Form SSA-821-BK (09-2009)
ef (09-2009)

Form Approved
OMB No. 0960-0059

SOCIAL SECURITY ADMINISTRATION

WORK ACTIVITY REPORT — EMPLOYEE
IDENTIFICATION - TO BE COMPLETED BY SSA
Name of Claimant or Beneficiary

Claimant or Beneficiary's SSN

Name of Wage Earner (if different from Claimant or Beneficiary)

Blind

-

Not Blind

Wage Earner's SSN

- Claimant or Beneficiary is Receiving:

Social Security Disability Insurance (SSDI) Benefits

Both SSDI and SSI Disability Benefits

Supplemental Security Income (SSI) Disability Benefits

Neither SSDI or SSI Disability Benefits

PART I - TO BE COMPLETED BY SSA
1.

Please use this form to tell us about your work since

2.

We need to know this information because:

Date

u

ANSWER THE QUESTIONS ON THIS FORM AND RETURN IT AND ANY OTHER INFORMATION ABOUT YOUR CLAIM
TO THE SOCIAL SECURITY OFFICE THAT GAVE (OR SENT) YOU THE FORM.
PART II - TO BE COMPLETED BY PERSONS APPLYING FOR OR RECEIVING BENEFITS
You should answer each of the questions below as best and with as many details as you can. This information will help us decide if you
should get or keep getting benefits. For any question below, if you need more space, use item 9, on pages 5 and 6. Remember to write the
number of the question that you are answering in item 9.
1.

HAVE YOU WORKED SINCE THE DATE SHOWN IN ITEM 1 OF PART 1, ABOVE?
YES If you did work, go to item 3 and answer the rest of the questions and sign and date the form.
NO

2.

If you did not work, but earnings were reported for you as shown in item 2 of Part I above, go to item 2 below.

REPORTED WORK OR EARNINGS
If you did not work, but earnings were reported for you as shown in Item 2 of Part 1, explain what the pay was for.
For example, sometimes pay is sick pay, vacation pay or holiday pay that you earned, or for work that you did before becoming unable
to work because of your condition.
If you can't explain the earnings reported for you or you don't remember what the total earnings are for, ask your employer(s). If your
employer(s) cannot help you, ask your local Social Security Office to help you.
Explanation of Earnings:

If you need more space, use Item 9. Then go to Items 8 and 10.
Form SSA-821-BK (09-2009) ef (09-2009) Formerly SSA-821-F4 & SSA-3945-BK

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Destroy Prior Editions

3.

TELL US ABOUT YOUR WORK SINCE THE DATE IN ITEM 1 OF PART 1 ABOVE.
(If you are not sure about some things, ask your employer to help you. If you need more space, use Item 9, on pages 5 and 6.
Remember to write the number of the question that you are answering in Item 9.)

A.

Employer's Name

Date Work Started

Job Title

Employer's Address (Include street, city, state, & ZIP)

Date Work Ended

Number of Hours (on average)
Worked
Per Day

Starting Hourly Pay

Current or Ending Pay

Supervisor's Name

Supervisor's Telephone
Number (Include area code)

Per Week

Check each block below that is true for this work:
I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
type of work I was doing (e.g., You were a plumber and changed to lighter work.) because:
of my medical condition.
special conditions at work related to my medical condition that allowed me to work were removed.
I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

B.

Prior Employer's Name

Date Work Started

Job Title

Employer's Address (Include street, city, state, & ZIP)

Date Work Ended

Number of Hours (on average)
Worked
Per Day

Starting Hourly Pay

Current or Ending Pay

Supervisor's Name

Supervisor's Telephone
Number (Include area code)

Per Week

Check each block below that is true for this work:
I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
type of work I was doing (e.g., You were a plumber and changed to lighter work.) because:
of my medical condition.
special conditions at work related to my medical condition that allowed me to work were removed.
I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

Form SSA-821-BK (09-2009) ef (09-2009 )

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C.

Prior Employer's Name

Employer's Address (Include street, city, state, & ZIP)

Date Work Started

Date Work Ended

Starting Hourly Pay

Current or Ending Pay

Supervisor's Name

Supervisor's Telephone
Number (Include area code)

Number of Hours (on average)
Worked

Job Title

Per Day

Per Week

Check each block below that is true for this work:
I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
type of work I was doing (e.g., You were a plumber and changed to lighter work.) because:
of my medical condition.
special conditions at work related to my medical condition that allowed me to work were removed.
I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

4.

Since the date you started working on or after the date shown in Item 1 of Part 1, above, have there been any months during which
you earned over $200 per month through 12/2000 or over $530 beginning 01/2001(before anything was withheld; e.g., taxes)?
No

(Go to Item 5.)

Yes

(Tell us which month and year and the amount you earned that month in the chart below. If you need more
space, use Item 9, on pages 5 and 6. Remember to write the number of the question that you are answering in Item 9.)

MONTH/YEAR

5.

AMOUNT

MONTH/YEAR

AMOUNT

MONTH/YEAR

AMOUNT

$

$

$

$

$

$

$

$

$

$

$

$

SPECIAL WORK CONDITIONS - Do (Did) you get special help on-the-job or extra pay in any of the jobs that you told us about
in Item 3?
No

(Go to Item 6.)

Yes Check all of the boxes that are true for you and tell us for which job(s) you received that help and tell us
about any other special condition(s) or help that you got on a job.
I needed and got special help from other
workers in doing my job.

I was given a job based on my past services to an
employer.

I was given special equipment or was given
work that was suited to my condition.

I worked irregular hours or took frequent rest periods.

I was allowed to work at a lower standard of
productivity.
I worked for a relative or friend.
Form SSA-821-BK (09-2009) ef (09-2009)

I worked in a sheltered work center.
I was hired through a special program for training or
therapy (e.g., vocational rehabilitation, supported
employment).
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5.

SPECIAL WORK CONDITIONS - Continued
Check all of the boxes that are true for you and tell us for which job(s) you received that help and tell us about any other special
condition(s) or help that you got on a job.
My job duties were different than other workers’ job duties doing the same work because:
I worked fewer hours.

I got different pay.

I had different duties; fewer or easier duties.

I had extra help, extra supervision, or a job coach.

I was given special transportation to and from work.

I got special help getting ready for work.

I was paid for extra rest periods at work or extra time off from work and other workers were not.
Other special help. (Explain below.)
In the space below, tell us for which job(s) you received the special help. If you need more space, use Item 9.

6.

OTHER/SPECIAL PAYMENTS - Do (Did) you get any payment(s) from an employer in addition to regular pay? For example, did you
get any tips, bonuses, sick or disability pay, vacation pay, meals, room or rent, transportation or use of a car or vehicle, or childcare?
No

Go to Item 7.

Yes Tell us below what these payments were. If you need more space, use Item 9.

EMPLOYER

AMOUNT OR ESTIMATE
OF THE DOLLAR VALUE

TYPE OF PAYMENT

MONTH & YEAR

$
$
$
$
$
7.

SPECIAL WORK EXPENSES (IMPAIRMENT-RELATED WORK EXPENSES) - Do (Did) you spend any money of your own earnings
for any things or services related to your condition that allowed you to work and for which you did not get paid back?
For example, medicines, bandages, braces, wheelchair, artificial arm or leg, braille equipment, special telephone or computer
equipment, modifications to home (wider doorways, roll-in shower, ramps, wheelchair-lift), or modifications to a car (automatic
wheelchair-lift), personal assistance (personal care attendant).
No

Go to Item 8.

Yes

Tell us below about the bills, or part of the bills, that you paid for things or services related to your medical
condition that you needed in order to work. (Upon review, you may be required to provide proof of these
expenses.) Do not show any bills or amounts paid by an insurance company or any other organization or
person or paid back to you by an insurance company or other organization or person. (Example: An
insurance company might pay all or part of the bill at a later time.)

Form SSA-821-BK (09-2009) ef (09-2009)

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7.

SPECIAL WORK EXPENSES (IMPAIRMENT-RELATED WORK EXPENSES) - Continued
ITEM OR SERVICE

COST

DATE(S) PAID (MONTH & YEAR)

$
$
$
$
$
$
SPECIAL TRANSPORTATION

8.

COST

MODIFIED VEHICLE

$

TAXI-TYPE SERVICE

$

VOCATIONAL REHABILITATION - Are (Were) you getting any help from a vocational rehabilitation or employment services provider
to get the services and/or training you need to get ready to start working, find work or keep working?
No

If you answered no, would you like to get these services?

Yes

No

Go to Item 10.

Yes

Tell us the name and address of the people who are (were) giving you vocational rehabilitation or employment
services and training.
Vocational Rehabilitation/Employment Services Provider

Name

Address (Include street, city, state & ZIP)

Counselor's Name

Counselor's Telephone Number (Include area code)

If you need more space, go to Item 9, below .
9.

More Space. For any question above, if you need more space, use space below. Remember to write the number of the question that
you are answering before you begin.

Form SSA-821-BK (09-2009) ef (09-2009)

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9.

More Space - Continued. For any question above, if you need more space, use space below. Remember to write the number of the
question that you are answering before you begin.

10. 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 medical condition or my work.
SIGN AND DATE THIS FORM
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.
Telephone Number (Include area code &
Signature of Claimant, Beneficiary, or Representative Date
e-mail address)

Mailing Address (Number and Street)

City and State

ZIP Code

County

Witnesses must sign ONLY if this statement is signed by mark (e.g., X) above. If signed by mark (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
2. Signature of Witness

Address (Number and street, city, state, and ZIP code)

Address (Number and street, city, state, and ZIP code)

Telephone Number (Include area code)

Telephone Number (Include area code)

Form SSA-821-BK (09-2009) ef (09-2009)

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PRIVACY ACT/PAPERWORK REDUCTION ACT STATEMENT
Sections 205(a), 223(d), 1612, 1613 and 1633(a) of the Social Security Act, as amended, authorize us to collect this
information. The information is needed to make a determination on your claim. The information you furnish on this
form is voluntary. However, failure to provide all or part of the information could prevent an accurate and timely
decision on your benefit eligibility.
We rarely use the information you supply for any purpose other than for making a determination on your disability
claim. 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 other agencies providing services to disabled children;
(5) to contractors for the purpose of assisting SSA in the administration of the Ticket to Work and Self Sufficiency
Program; and (6) 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 System of Records Notice 60-0050, 60-0089,
60-0295, 60-0320. The notices, additional information regarding this form, and information regarding our programs
and systems, are available on-line at www.ssa.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. We estimate that it will take about
45 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. To find the nearest office, call
1-800-772-1213 TTY# (TTY 1-800-325-0778). Send only comments on our time estimate above to: SSA, 6401
Security Blvd., Baltimore, MD 21235-6401.

Form SSA-821-BK (09-2009) ef (09-2009)

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FOR SSA USE ONLY - DO NOT WRITE ON THIS PAGE
11. A. Contact made:
In Person

By Mail

By Telephone

Other

B. Completed by:
Claimant

SSA Representative

Other

If "Other," show:
Name

Telephone Number

Address

Relationship
12. Interviewer/Reviewer Checklist. SSA interviewers and reviewers should check all items that apply and discuss all "YES" or "NO"
answers below, except for reminder items or when a final determination is prepared.
A. Work within waiting period or within 12 months of onset (SGA denial or reopening/revision
to denial applies)

YES

NO

B. MIE diary involved - DDS referral needed

YES

NO

C. Title II TWP determination

YES

NO

D. Special considerations, situations, assistance (Subsidy - specific or nonspecific)

YES

NO

E. IRWE

YES

NO

F. SGA (after applicable subsidy /IRWE deduction (s))

YES

NO

G. UWA (initial claim - DDS jurisdiction. FO has documented significant break in work and made
UWA recommendation to DDS for a final determination)

YES

NO

H. UWA (Continuing disability review - FO jurisdiction)

YES

NO

I. EPE impairment severity issue - DDS referral needed (reminder item)

YES

NO

J. EPE reinstatement/suspension/termination

YES

NO

K. Due process required

YES

NO

L. Concurrent Title II & Title XVI Income & Resources or 1619 action needed

YES

NO

M. Other issue(s)/comment(s) not noted above

YES

NO

Discussion:

13. Signature and title of SSA interviewer/reviewer

Form SSA-821-BK (09-2009) ef (09-2009)

14. FO/PSC code 15. Telephone Number

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16. Date