SSA-821-BK Form – Fill Out and Use This PDF

The SSA-821-BK form, utilized by the Social Security Administration (SSA), is a critical document designed to gather detailed information about an individual's work activity. This form plays a vital role in determining eligibility for disability benefits, ensuring that recipients meet the necessary work requirements. It's imperative for individuals applying for or currently receiving disability benefits to fill out and return this form accurately to avoid any potential disruption in their benefits. For detailed instructions and assistance in completing the form, click the button below.

Get Form Now Download PDF

SSA-821-BK Form PDF Details

The Social Security Administration (SSA) operates under a commitment to support individuals who are unable to work due to disability. A critical component of this support system is the thorough evaluation and verification of an individual's work activity to ensure the appropriate distribution of benefits. The SSA-821-BK form, formally titled "Work Activity Report - Employee," plays a pivotal role in this process. When individuals receiving disability benefits begin or return to work, the SSA necessitates the completion of this form to assess the impact of employment on their disability status. It is designed to gather detailed information about one's employment, including dates of employment, earnings, type of work performed, and any additional benefits or payments received from the employer. This information is crucial for the SSA to determine eligibility for continued benefits or adjustments to the benefit amount. The form emphasizes the urgency of accurate and comprehensive disclosure, guiding claimants through the process of reporting their work activity since a specified date. Additionally, it provides directives for including supplementary information such as pay stubs or other proof of earnings. With strict deadlines for submission, the SSA seeks to maintain an efficient evaluation process to ensure that individuals receive the support they need in a timely manner, while also upholding the integrity of the disability benefits program.

Question	Answer
Form Name	SSA-821-BK Form
Form Length	12 pages
Fillable?	Yes
Fillable fields	1
Avg. time to fill out	3 min 12 sec
Other names	ssa 821 821 form 2012

Form Preview Example

Form SSA-821-BK (02-2021) UF	Page 1 of 12
Discontinue Prior Editions	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-BK (02-2021) 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 at www.ssa.gov/pubs/10095.html online.

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.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 FBU's.

○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-821-BK (02-2021) UF
Discontinue Prior Editions	Page 3 of 12
Social Security Administration	OMB No. 0960-0059

Work Activity Report - Employee

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

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 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

Name and Address of Payer

Amount

Date Worked

(MM/YYYY-MM/YYYY)

ABC Company

100.00 per day, week,

Example

123 Any Street

01/2000 - 02/2000

month, or year

Your Town, MD 54321

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 (02-2021) 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

$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	Amount	Date Earned	Amount	Date Earned	Amount
MM/YYYY	Amount	MM/YYYY	Amount	MM/YYYY	Amount
MM/YYYY		MM/YYYY		MM/YYYY

	$		$		$

	$		$		$

	$		$		$

	$		$		$

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	Amount	Date Earned	Amount	Date Earned	Amount
MM/YYYY	Amount	MM/YYYY	Amount	MM/YYYY	Amount
MM/YYYY		MM/YYYY		MM/YYYY

	$		$		$

	$		$		$

	$		$		$

	$		$		$

Form SSA-821-BK (02-2021) 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	Amount	Date Earned	Amount	Date Earned	Amount
MM/YYYY	Amount	MM/YYYY	Amount	MM/YYYY	Amount
MM/YYYY		MM/YYYY		MM/YYYY

	$		$		$

	$		$		$

	$		$		$

	$		$		$

	If you have more employers, go to Additional Employment Information.

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
Transportation	Car or Vehicle
Other (Please explain):

Vacation Pay Childcare

Tips

Meals

Bonus

Room or Rent

Type of Payment	Employer Name	Amount or Estimate of Value			Date Received
Type of Payment	Employer Name	Amount or Estimate of Value			(MM/YYYY-MM/YYYY)
					(MM/YYYY-MM/YYYY)

Example: Sick Pay	ABC Company	$	100.00 per day, week,		01/2000 - 02/2000
Example: Sick Pay	ABC Company		month, or year		01/2000 - 02/2000
			month, or year

		$		per


		$		per


		$		per

Form SSA-821-BK (02-2021) 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?

			Date
Yes	Special Condition	Employer Name	(MM/YYYY to	Please Describe
			MM/YYYY)

	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)

None of the above apply. Go to Question 6A.

Form SSA-821-BK (02-2021) 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	Reasons for Changes in Work Activity
Yes	Special Condition	Employer Name	(MM/DD/YYYY)	Reasons for Changes in Work Activity
			(MM/DD/YYYY)

				My physical and/or mental condition(s)
	Stopped working			Special conditions that allowed me to work
	Stopped working			were removed
				were removed
				Other reasons (please explain in 6B)

				My physical and/or mental condition(s)
	Reduced my work			Special conditions that allowed me to work
	hours			were removed
				Other reasons (please explain in 6B)

				My physical and/or mental condition(s)
	Reduced my earnings			Special conditions that allowed me to work
	Reduced my earnings			were removed
				were removed
				Other reasons (please explain in 6B)

				My physical and/or mental condition(s)
	Changed to a lighter or			Special conditions that allowed me to work
	easier type of 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 (02-2021) 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			Cost		Date Paid
Describe Item or Service			Cost		(MM/YYYY-MM/YYYY)
					(MM/YYYY-MM/YYYY)

Example: Service animal		$	100.00 per day, week,		01/2000 - 02/2000
Example: Service animal			month, or year		01/2000 - 02/2000
			month, or year

		$		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-821-BK (02-2021) 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

Form SSA-821-BK (02-2021) 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 (02-2021) 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

$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	Amount	Date Earned		Amount	Date Earned		Amount
MM/YYYY	Amount	MM/YYYY		Amount	MM/YYYY		Amount
MM/YYYY		MM/YYYY			MM/YYYY

	$			$			$

	$			$			$

	$			$			$

	$			$			$

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	Amount	Date Earned	Amount	Date Earned	Amount
MM/YYYY	Amount	MM/YYYY	Amount	MM/YYYY	Amount
MM/YYYY		MM/YYYY		MM/YYYY

	$		$		$

	$		$		$

	$		$		$

	$		$		$

Form SSA-821-BK (02-2021) 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

$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	Amount	Date Earned		Amount		Date Earned			Amount
MM/YYYY	Amount	MM/YYYY		Amount		MM/YYYY			Amount
MM/YYYY		MM/YYYY				MM/YYYY

	$			$				$

	$			$				$

	$			$				$

	$			$				$

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	Amount	Date Earned	Amount	Date Earned	Amount
MM/YYYY	Amount	MM/YYYY	Amount	MM/YYYY	Amount
MM/YYYY		MM/YYYY		MM/YYYY

	$		$		$

	$		$		$

	$		$		$

	$		$		$

How to Edit SSA-821-BK Form Online for Free

You are able to complete Ssa Form 821 Bk without difficulty in our PDFinity® online tool. FormsPal team is committed to providing you with the ideal experience with our tool by continuously introducing new features and upgrades. With all of these updates, using our editor becomes easier than ever! With some simple steps, you'll be able to start your PDF journey:

Step 1: Click on the "Get Form" button above on this page to get into our tool.

Step 2: As you open the file editor, you'll see the document ready to be filled in. In addition to filling in different blank fields, you might also do other actions with the PDF, specifically writing your own text, modifying the original text, inserting images, affixing your signature to the document, and a lot more.

With regards to the blanks of this specific form, this is what you should do:

1. Start filling out your Ssa Form 821 Bk with a selection of necessary blank fields. Collect all the required information and make certain nothing is overlooked!

Step no. 1 in completing Ssa Form 821 Bk

2. The subsequent step would be to fill out these blank fields: Employer Name, Year, and Earnings.

3. Throughout this part, look at Visit our website at wwwssagov to, call your Social Security contact, Write or visit any Social, make an appointment The office, If you are deaf or hard of hearing, and If you are in Canada visit. All of these are required to be filled in with highest attention to detail.

If you are in Canada visit, Write or visit any Social, and Visit our website at wwwssagov to of Ssa Form 821 Bk

4. It is time to begin working on this fourth part! In this case you will get all of these Name of Claimant or Beneficiary, BNC, Identification To Be Completed by, Blind, Not Blind, Please use this form to describe, Date, Information To Be Completed By, Please answer each of the, Have you had any employment, NO If you did not work but income, YES Go to Question, If you did not work other types, ask you for proof of this income, and Type of Payment empty form fields to fill in.

NO If you did not work but income, Type of Payment, and Blind inside Ssa Form 821 Bk

5. To finish your document, the last part incorporates a few extra blanks. Entering Holiday Pay, Bonus or Commission, Royalties, Sick Pay, Disability Pay, Insurance Payment, Workers Comp, Other Please explain, per, per, per, per, per, per, and per should finalize everything and you can be done very quickly!

Holiday Pay, per, and per of Ssa Form 821 Bk

People often make some mistakes when filling out Holiday Pay in this area. Be certain to re-examine what you type in right here.

Step 3: Make certain your information is right and then click "Done" to proceed further. Find the Ssa Form 821 Bk when you join for a 7-day free trial. Immediately view the form from your FormsPal cabinet, along with any modifications and adjustments conveniently synced! Whenever you work with FormsPal, you're able to fill out documents without being concerned about personal data leaks or records being shared. Our secure platform ensures that your private data is kept safe.

SSA-821-BK Form – Fill Out and Use This PDF

SSA-821-BK Form PDF Details

Form Preview Example

How to Edit SSA-821-BK Form Online for Free

SSA-821-BK Form isn’t the one you’re looking for?

Related Documents