Work Activity Report (Self-Employed Person)

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
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 you provide to determine benefits eligibility. We may also share the
information for the following purposes, called routine uses:
•

To officers and employees of Federal, State or local agencies upon written request, in
accordance with the Internal Revenue Code (IRC) (U.S.C. 6103(l)(7)), tax return
information (e.g., information with respect to net earnings from self-employment,
wages, payments of retirement income which have been disclosed to the Social
Security Administration, and business and employment addresses) for purposes of,
and to the extent necessary in, determining an individual’s eligibility for, or the
correct amount of, benefits under certain programs listed in the IRC; and

•

To employers, current or former, for correcting or reconstructing earnings records and
for Social Security tax purposes.

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 Notice
(SORN) 60-0059, entitled Earnings Recording and Self-Employment Income System, as
published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819, and 60-0089, Claims
Folders System, as published in the FR on October 31, 2019, at 84 FR 58422. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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. We estimate that it will take about 30 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.