Form SSA-820-BK Work Activity Report (Self-Employment)

Form SSA-820-BK (MOCK UP) UF
Discontinue Prior Editions

Social Security Administration
Retirement, Survivors, and Disability Insurance

Page 1 of 8
OMB No. 0960-0598

Important Information

FO Address:

Date:
BNC#:

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 Need 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 will make our determination based on the evidence we have in our records.
Some Information To Help You Complete This Form
Our records show the following self-employment income 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.
Self-Employment

Year

Yearly Income

Form SSA-820-BK (MOCK UP) UF

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For More Information
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 at www.ssa.gov/pubs/10095.html online.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/report or call the Inspector
General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).
If You Have Questions
If you have any questions, or need help completing the form:

• Visit our website at www.ssa.gov to find general information about Social Security.
• Call us toll-free at 1-800-772-1213, or call your local office at
your Social Security contact,
questions over the phone.

, at

. You may also call
. We can answer most

• Write or visit any Social Security office. If you plan to visit an office, you may call ahead to make
an appointment. The office that serves your area is located at:

• If you are deaf or hard of hearing, our toll-free TTY number is 1-800-325-0778.
• If you are outside the United States or its territories:
• If you are in Canada, visit www.ssa.gov/foreign/canada.htm to find the office that services

your area.
• Contact your nearest Federal Benefits Unit (FBU). Visit www.ssa.gov/foreign/foreign.htm for
a list of FBUs.
• Write to the Social Security Administration at:
P.O. Box 17769
Baltimore, Maryland 21235-7769
USA

Please have this letter with you if you call or visit an office. If you write, please include a copy of this
letter. It will help us answer your questions.

Social Security Administration
Enclosures:
SSA Pub No. 05-10095
Pre-addressed Envelope

Form SSA-820-BK (MOCK UP) UF

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Work Activity Report - Self-Employment
Identification - To Be Completed by SSA

Name of Claimant or Beneficiary

BNC#

Blind
Not Blind

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 self-employment income 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 but income was reported for you, complete the information below. When you are finished, go to
Question 9.
Payment For

Name and Address of Payer

Amount or Estimate of Value

Example: Income
after business
stopped

ABC Company
123 Any Street
Your Town, MD 54321

Date Worked
(MM/YYYY-MM/YYYY)

$100 per day, week, month, or
year

01/2000 - 02/2000

$

per

$

per

3. Please tell us about your work since the DATE shown in the Identification section.
Type of Self-Employment or Name of Business

Area Code and Telephone Number Area Code and Fax Number

Mailing address

City

State

ZIP

What is the primary product or service?
Date Work Started (MM/DD/YYYY) Date Work Ended (if ended) (MM/DD/YYYY)

Average Number of Hours
Still working Worked per Month

Type of ownership arrangement? (Check one)
Sole Owner

Limited Liability Company (LLC)

Independent Contractor

Corporation

Partnership

Other (Please explain)

Farm Landlord

Farm Tenant

Form SSA-820-BK (MOCK UP) UF

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BNC#:
4. In the space below, show each month you worked in your business, the net earnings, and if you worked 45 hours
or more.
Date Worked
Worked more than 45
Date Worked
Worked more than 45
Net Earnings
Net Earnings
MM/YYYY
hours per month?
MM/YYYY
hours per month?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If you need more room for your answers, go to the Remarks section.
5. Please attach all of your self-employment tax returns (including Schedule C & SE or 1099) since the DATE shown in
the Identification section.
I have ENCLOSED my Tax Returns. Go to Question 6.
I DO NOT have Tax Returns. For any years that you DO NOT have tax returns, use the chart below to tell us
about your total annual gross and net self-employment income.
Year (YYYY)

Gross
$
$

Net

Year (YYYY)

$
$

Gross
$
$

Net
$
$

6. Has anyone besides yourself had management responsibilities for this business (i.e., a partner, employee, relative,
or helper) since the DATE shown in the Identification section?
NO. Go to Question 7.
YES. Complete the questions below.

•
•
•

How many hours per month (on average) does or did the other person(s) spend
on management duties?

Hours per month

How many hours per month (on average) do or did you spend on management
duties?

Hours per month

Please tell us what duties you and the other person performed below.

Form SSA-820-BK (MOCK UP) UF

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BNC#:

7. Since the DATE shown in the Identification section did you make any changes in your work activity due to your
physical and/or mental condition(s)?
NO. Go to Question 8.
YES. Please describe your changes below (Check all that apply below).
Type of change

Date (MM/DD/YYYY)

Please Explain

Stopped Working

Reduced my work hours

My hours reduced from

per

to

because

per

Changed to lighter or easier
work

Other changes

8. Has any person or organization contributed to or paid for any business expenses or provided any free help, items,
or services related to your business since the DATE shown in the Identification section (For example: rent,
supplies, inventory, purchase, repair of equipment, or an employee or helper that works for you for free)?
NO. Go to Question 9.
YES. Describe the expenses paid or items or services provided, their value of the contribution, and who
provided them below.

Form SSA-820-BK (MOCK UP) UF

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BNC#:
9. 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. Go to the next section.
YES. 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: Money spent for medicines

$100 per day, week, month, or year

01/2009 - 02/2009

$

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-820-BK (MOCK UP) UF

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BNC#:

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(s) 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
Mailing address

Date
City

Area Code and Telephone Number
State

ZIP

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
Mailing address
2. Signature of Witness
Mailing address

Date
City
Date
City

Area Code and Telephone Number
State

ZIP

Area Code and Telephone Number
State

ZIP

Form SSA-820-BK (MOCK UP) UF

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Privacy Act Statement
Collection and Use of Personal Information
Sections 223(d) and 1633 of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information
may prevent an accurate and timely decision on any claim filed.
We will use the information to make a determination of eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
1. To employers or former employers, including State Social Security administrators, for correcting
and reconstructing State employee earnings records and for Social Security purposes; and
2. To Federal, State, or local agencies for the purpose of validating Social Security numbers used
in administering cash or non-cash income maintenance programs or health maintenance
programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws.
For example, where authorized, we may use and disclose this information in computer matching
programs, in which our records are compared with other records to establish or verify a person's
eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these
programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORNs)
60-0059, entitled Earnings Recording and Self-Employment Income System and 60-0089, entitled
Claims Folders Systems. Additional information and a full listing of all our SORNs are available on
our website at www.socialsecurity.gov/foia/bluebook.

See Revised Privacy Act & PRA
Statements attached
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 0960-0598. We estimate that it will take about 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.