Ssa 820 Bk Form – Fill Out and Use This PDF

Form SSA-820-BK (04-2021) UF	Page 1 of 8
Discontinue Prior Editions	OMB No. 0960-0598

Social Security Administration

Retirement, Survivors, and Disability Insurance

Important Information

FO Address:

Date:

BNC#:

We are writing to you because we believe you may have recent work activity and we need to know

more about this work activity. Please tell us about your work since. If you are applying for disability benefits, the information you provide will help us decide if you can receive benefits. If you are currently receiving disability benefits, the information you provide helps us decide if you can continue to receive 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.

Income Reported for You

Form SSA-820-BK (04-2021) UF

Page 2 of 8

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						. 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 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 (04-2021) UF
Discontinue Prior Editions	Page 3 of 8
Social Security Administration	OMB No. 0960-0598

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		Date

(Insert alleged onset date, date of entitlement, or last determination date, as appropriate)

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. For a list of the income that was reported for you, please refer to page 1 in the section entitled Income Reported for You.

YES. Go to Question 3.

2. If you did not work, but income was reported for you, for each row on page 1 under the section Income Reported for You, please provide additional information about the income. If the income reported for you is an error, please explain in the Remarks section of the form. When you are finished go to the Signature section to complete the form.

	Self-Employment	Name and Address of Payer		Payment or estimate of value							Date Worked
	Description										(MM/YYYY-MM/YYYY)
	Example: Income	ABC Company		$		100 per day, week, month, or					01/2000 - 02/2000
	after business	123 Any Street
						year
	stopped	Your Town, MD 54321
				$			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

What is the primary product or service?

Form SSA-820-BK (04-2021) UF									Page 4 of 8
						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	Net Earnings	Worked more than 45		Date Worked	Net Earnings		Worked more than 45
	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?

Form SSA-820-BK (04-2021) UF	Page 7 of 8

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.

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		City		State	ZIP
2. Signature of Witness	Date		Area Code and Telephone Number
Mailing address		City		State	ZIP