Information Collection

Work Activity Report (Self-Employed Person)

IC 9580 under ICR 202106-0960-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
Work CDR Sample Notice.pdf	Other-Work CDR Sample Notice
Work CDR Sample Notice.pdf	Other-Work CDR Sample Notice
SSA-820-BK Work Activity Report (Self-Employment) SSA-820-BK - Revised.pdf www.socialsecurity.gov	Form
SSA-820-BK Work Activity Report (Self-Employment) SSA-820-BK - Revised.pdf www.socialsecurity.gov	Form
SSA-820-APP SSA-820-APP SSA-820-APP Screens.pdf	Form and Instruction
SSA-820-APP SSA-820-APP SSA-820-APP Screens.pdf	Form and Instruction
SSA-820-BK - Current.pdf SSA-820-BK - Current	IC Document
SSA-820-BK - Current.pdf SSA-820-BK - Current	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 404.1571-1576 20 CFR 416.971-.976 20 CFR 404.1584-.1593 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 - Revised.pdf	www.socialsecurity.gov	Yes	No	Fillable Printable
Other-Work CDR Sample Notice			Work CDR Sample Notice.pdf		No		Paper Only
Form and Instruction	SSA-820-APP	SSA-820-APP	SSA-820-APP Screens.pdf		Yes	Yes	Fillable Fileable Signable

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	Previously Approved
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	50,000	50,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-820-BK - Current	SSA-820-BK - Current.pdf	10/19/2020

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