Fillable Form SSA-821-BK work activity report employee Social Security

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Form SSA-821-BK work activity report employee Social Security

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  • 80 check-boxes
  • 431 other fields

Country of origin: US
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Form SSA-821-BK (01-2019) UF
Discontinue Prior Editions
Page 1 of 12
OMB No. 0960-0059
Social Security Administration
Retirement, Survivors, and Disability Insurance
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 may contact your employer or make our determination based on the
evidence we have in our records.
Some Information To Help You Complete This Form
Our records show these employers and yearly earnings 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.
Employer Name Year Earnings
Form SSA-821 (01-2019) UF Page 2 of 12
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 online at www.ssa.gov/pubs/10095.html
.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit https://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.socialsecurity.gov
to find general information about Social Security.
•
Call us toll-free at 1-800-772-1213, or call your local office at . You may also
call your Social Security contact, at . We can answer
most questions over the phone.
•
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 live outside the United States, please contact any Social Security office or the nearest
United States Embassy or consulate. If you live in the Philippines, you may contact the
Veterans Administration Regional Office, Social Security Division, 1131 Roxas Boulevard,
Manila. You may also write to the Social Security Administration, P.O. Box 17775, Baltimore,
Maryland, 21235-7775, 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-821-BK (01-2019) UF
Discontinue Prior Editions
Social Security Administration
Page 3 of 12
OMB No. 0960-0059
Work Activity Report - Employee
Identification - To Be Completed by SSA
Name of Claimant or Beneficiary Claimant or Beneficiary's Own SSN
Blind
Not Blind
Claim Number & BIC
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 employment income or wages 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, other types of income may have been reported for you. Please complete the information below. We may
ask you for proof of this income. When you are finished, go to Question 7.
Type of Payment
Example
Name and Address of Payer
ABC Company
123 Any Street
Your Town, MD 54321
Amount
$100 per day, week,
month, or year
Date Worked
(MM/YYYY-MM/YYYY)
01/2000 - 02/2000
Back Pay
$ per
Vacation Pay
$ per
Holiday Pay
$ per
Bonus or Commission
$ per
Royalties
$ per
Sick Pay
$ per
Disability Pay
$ per
Insurance Payment
$ per
Workers Comp
$ per
Other (Please explain)
$ per
Form SSA-821-BK (01-2019) UF Page 4 of 12
BNC #:
3A. Please tell us about your work since the DATE shown in the Identification section, beginning with your most recent
employer. If you are not sure about this, ask your employer(s) to help you. Use the additional space provided in the Remarks
section if you need more room for your answer.
Current or Most Recent Employer's Name Supervisor's Name
Supervisor's Telephone No.
(include area code)
Mailing Address City State ZIP Code
Job Title and Type of Work
Date Work Started
(MM/DD/YYYY)
Date Work Ended (if ended)
(MM/DD/YYYY)
Still working
Rate of Pay
Hours Worked per
Week (on average)
$ per
Attach copies of all your pay stubs from this employer or ask the employer for a wage print-out showing gross monthly earnings
since the DATE shown in the Identification section.
I have ENCLOSED Pay Stubs or Gross Wage Print Outs.
I DO NOT have Pay Stubs or Gross Wage Print Outs. For any months that you DO NOT have pay stubs or a
print-out, use the chart below to tell us how much you earned (before deductions) in each month.
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
$
$
$
$
$
$
$
$
$
$
$
$
3B. If you do not have any more employers, go to Question 4.
Previous Employer's Name Supervisor's Name
Supervisor's Telephone No.
(include area code)
Mailing Address City State ZIP Code
Job Title and Type of Work
Date Work Started
(MM/DD/YYYY)
Date Work Ended (if ended)
(MM/DD/YYYY)
Still working
Rate of Pay
$ per
Hours Worked per
Week (on average)
Attach copies of all your pay stubs from this employer or ask the employer for a wage print-out showing gross monthly earnings
since the DATE shown in the Identification section.
I have ENCLOSED Pay Stubs or Gross Wage Print Outs.
I DO NOT have Pay Stubs or Gross Wage Print Outs. For any months that you DO NOT have pay stubs or a
print-out, use the chart below to tell us how much you earned (before deductions) in each month.
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
$
$
$
$
$
$
$
$
$
$
$
$
Form SSA-821-BK (01-2019) UF Page 5 of 12
BNC #:
3C. If you do not have any more employers, go to Question 4.
Previous Employer's Name Supervisor's Name
Supervisor's Telephone No.
(include area code)
Mailing Address City State ZIP Code
Job Title and Type of Work
Date Work Started
(MM/DD/YYYY)
Date Work Ended (if ended)
(MM/DD/YYYY)
Still working
Rate of Pay
$ per
Hours Worked per
Week (on average)
Attach copies of all your pay stubs from this employer or ask the employer for a wage print-out showing gross monthly earnings
since the DATE shown in the Identification section.
I have ENCLOSED Pay Stubs or Gross Wage Print Outs.
I DO NOT have Pay Stubs or Gross Wage Print Outs. For any months that you DO NOT have pay stubs or a
print-out, use the chart below to tell us how much you earned (before deductions) in each month.
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
$
$
$
$
$
$
$
$
$
$
$
$
If you have more employers, go to the Remarks Section.
4. Do or did you get any other payment(s) or benefit(s) from an employer in addition to the regular pay shown in Question 3?
NO. Go to Question 5.
YES. Please check all that apply below.
Sick Pay Disability Pay Vacation Pay Tips Bonus
Transportation Car or Vehicle Childcare Meals Room or Rent
Other
(Please explain):
Type of Payment
Example: Sick Pay
Employer Name
ABC Company
Amount or Estimate of Value
$100 per day, week,
month, or year
Date Received
(MM/YYYY-MM/YYYY)
01/2000 - 02/2000
$ per
$ per
$ per
Form SSA-821-BK (01-2019) UF Page 6 of 12
BNC #:
5. For any job(s) that you told us about in Question 3, have you worked under any special conditions listed below?
Yes Special Condition Employer Name
Date
(MM/YYYY to
MM/YYYY)
Please Describe
Had extra help, extra
supervision or a job coach
Worked irregular or fewer
hours than other workers
Given special equipment
because of my condition
Took more rest periods than
other workers
Given special transportation to
and from work
Had fewer or easier duties than
other workers
Allowed to produce less work
than other workers
Hired through special training
or therapy program
Given work that was suited to
my condition
Given special help getting
ready for work
Other (explain)
Other (explain)
None of the above apply. Go to Question 6A.
Form SSA-821-BK (01-2019) UF Page 7 of 12
BNC #:
6A. For any job that you told us about in Question 3, did you make any of the changes below since the DATE shown in the
Identification section (Check all that apply).
Yes Special Condition Employer Name
Date
(MM/DD/YYYY)
Reasons for Changes in Work Activity
Stopped working
My physical and/or mental condition(s)
Special conditions that allowed me to work
were removed
Other reasons (please explain in 6B)
Reduced my work
hours
My physical and/or mental condition(s)
Special conditions that allowed me to work
were removed
Other reasons (please explain in 6B)
Reduced my earnings
My physical and/or mental condition(s)
Special conditions that allowed me to work
were removed
Other reasons (please explain in 6B)
Changed to a lighter or
easier type of work
My physical and/or mental condition(s)
Special conditions that allowed me to work
were removed
Other reasons (please explain in 6B)
No, I did not make any changes since the date shown in the Identification section. Go to Question 7.
6B. Use this space to provide any additional information about your work changes.
Form SSA-821-BK (01-2019) UF Page 8 of 12
BNC #:
7. 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. I did not spend any of my own money for items or services related to my physical and/or mental condition.
YES. Please 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
Example: Service animal
Cost
$100 per day, week,
month, or year
Date Paid
(MM/YYYY-MM/YYYY)
01/2000 - 02/2000
$ per
$ per
$ per
$ per
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.
Remarks
Form SSA-821-BK (01-2019) UF Page 9 of 12
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
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 Date
Area Code and
Telephone Number
Mailing Address (Number and Street, Apt. no., P.O. Box, or Rural Route) City State ZIP Code
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 Date
Area Code and
Telephone Number
Mailing Address (Number and Street, Apt. no., P.O. Box, or Rural Route) City State ZIP Code
2. Signature of Witness Date
Area Code and
Telephone Number
Mailing Address (Number and Street, Apt. no., P.O. Box, or Rural Route) City State ZIP Code
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Form SSA-821-BK (01-2019) UF Page 10 of 12
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 or could result in an overpayment of benefits.
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:
• To employers or former employers for correcting or reconstructing earnings records and for
Social Security tax purposes only; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting Social
Security Administration in the efficient administration of its 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 (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, 60-0320, entitled Electronic Disability Claim File, as
published in the FR on December 22, 2003, at 68 FR 71210, and 60-0330, entitled eWork, as published
in the FR on September 15, 2003, at 68 FR 54037. Additional information, and a full listing of all 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. The OMB control number for this collection is
0960-0059. We estimate that it will take about 40 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.
Form SSA-821-BK (01-2019) UF Page 11 of 12
BNC #:
ADDITIONAL EMPLOYMENT INFORMATION
(Continuation from Page 5)
Employer's Name Supervisor's Name
Supervisor's Telephone No.
(include area code)
Mailing Address City State ZIP Code
Job Title and Type of Work
Date Work Started
(MM/DD/YYYY)
Date Work Ended (if ended)
(MM/DD/YYYY)
Still working
Rate of Pay
Hours Worked per
Week (on average)
$ per
Attach copies of all your pay stubs from this employer or ask the employer for a wage print-out showing gross monthly earnings
since the DATE shown in the Identification section.
I have ENCLOSED Pay Stubs or Gross Wage Print Outs.
I DO NOT have Pay Stubs or Gross Wage Print Outs. For any months that you DO NOT have pay stubs or a
print-out, use the chart below to tell us how much you earned (before deductions) in each month.
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
$
$
$
$
$
$
$
$
$
$
$
$
Employer's Name Supervisor's Name
Supervisor's Telephone No.
(include area code)
Mailing Address City State ZIP Code
Job Title and Type of Work
Date Work Started
(MM/DD/YYYY)
Date Work Ended (if ended)
(MM/DD/YYYY)
Still working
Rate of Pay
Hours Worked per
Week (on average)
$ per
Attach copies of all your pay stubs from this employer or ask the employer for a wage print-out showing gross monthly earnings
since the DATE shown in the Identification section.
I have ENCLOSED Pay Stubs or Gross Wage Print Outs.
I DO NOT have Pay Stubs or Gross Wage Print Outs. For any months that you DO NOT have pay stubs or a
print-out, use the chart below to tell us how much you earned (before deductions) in each month.
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
$
$
$
$
$
$
$
$
$
$
$
$
Form SSA-821-BK (01-2019) UF Page 12 of 12
BNC #:
ADDITIONAL EMPLOYMENT INFORMATION
(Continuation from Page 5)
Employer's Name Supervisor's Name
Supervisor's Telephone No.
(include area code)
Mailing Address City State ZIP Code
Job Title and Type of Work
Date Work Started
(MM/DD/YYYY)
Date Work Ended (if ended)
(MM/DD/YYYY)
Still working
Rate of Pay
Hours Worked per
Week (on average)
$ per
Attach copies of all your pay stubs from this employer or ask the employer for a wage print-out showing gross monthly earnings
since the DATE shown in the Identification section.
I have ENCLOSED Pay Stubs or Gross Wage Print Outs.
I DO NOT have Pay Stubs or Gross Wage Print Outs. For any months that you DO NOT have pay stubs or a
print-out, use the chart below to tell us how much you earned (before deductions) in each month.
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
$
$
$
$
$
$
$
$
$
$
$
$
Employer's Name Supervisor's Name
Supervisor's Telephone No.
(include area code)
Mailing Address City State ZIP Code
Job Title and Type of Work
Date Work Started
(MM/DD/YYYY)
Date Work Ended (if ended)
(MM/DD/YYYY)
Still working
Rate of Pay
Hours Worked per
Week (on average)
$ per
Attach copies of all your pay stubs from this employer or ask the employer for a wage print-out showing gross monthly earnings
since the DATE shown in the Identification section.
I have ENCLOSED Pay Stubs or Gross Wage Print Outs.
I DO NOT have Pay Stubs or Gross Wage Print Outs. For any months that you DO NOT have pay stubs or a
print-out, use the chart below to tell us how much you earned (before deductions) in each month.
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
Date Earned
MM/YYYY
Amount
$
$
$
$
$
$
$
$
$
$
$
$
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Form SSA-821-BK work activity report employee Social Security

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Completed 21 February 2020

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