Form SSA-1458 Certification by Religious Group

Social Security Administration

Form Approved
OMB NO. 0960-0046

TOE 320

STATEMENT OF SELF-EMPLOYMENT INCOME

PRIVACY ACTIPAPERWORK ACT NOTICE: Your response to this request is voluntary; however. failure to provide all or any part of the information requested may
affect the final decision on your claim. The information requested on this form is authorized by sections 404.101 and 404,1 09(aHc) of the Social Security
Regulations. The information you furnish will enable the Social Security Administration to determine whether self-employment income for the current taxable year
may be used in determining your eligibility for Social Security benefits. Information you furnish on this form may be disclosed by the Social Security Administration
to another person or governmental agency only with respect to Social Security programs and to comply with Federal laws requiring the exchange of information
between the Social Security Administration and another agency.
This information collection meets the clearance requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 5 minutes
to read the instructions, gather the necessary facts, and answer the questions.

See below for revised Privacy Act and
Paperwork Reduction Act Statements.

1. NAME OF SELF-EMPlOYED PERSON

2. SOCIAL SECURITY NUMBER

3. NAME AND ADDRESS OF TRADE OR BUSINESS

4, NATURE OF TRADE OR BUSINESS

5. Net earnings from self-employment for the period from:

to

In answering items numbered 6, 7, and 8 follow the same general rules used for computing your net earnings
from self-employment on your Federal income tax return. (This is only an estimate of self-employment income and
does not relieve the seff-employed person from filing the proper tax return at the end of the taxable year.)

6. The gross income of this business during the above period was not less than

$

7. The total business expenses during the same period were not more than

$

8. The net earnings were not less than (item 6 less item 7)

$

9. If your actual net earnings at the end of your taxable year are less than $400. will
you report your self-employment income under the optional method?

DYes

DNo

ANSWER 10 IN ALL CASES

10. Give the basis for your knowledge of the amounts shown above:

I know that anyone who makes or causes to be made a false statement or representation of material fact in an
application or for use in determining a right to payment under the Social Security Act commits a crime punishable
under Federal law by fine, imprisonment or both. I affirm that all information I have given in this document is true.
DATE

FOAM

SIGNATURE OF SelF-EMPLOYED PERSON OR WHERE SELF-EMPLOYED PERSON IS DECEASED OR INCOMPETENT.
OF PERSON HAVING KNOWLEDGE OF THE FACTS.

SSA-766 15·19831

EF (9-20001

·U-S. Government Printing Office: 2001-491-689160020

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 control number. We estimate that it will take about 5
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.

PRIVACY ACT STATEMENT 

Sections 404.101 and 404.109(a)(c) of the Social Security Act, as amended, authorize us to
collect this information. We will use your self-employment income information for the current
taxable year to determine your eligibility for Social Security benefits.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from making an accurate and timely decision on your
claim, which may result in the loss of payments.
We rarely use the information you supply for any purposes other than for determining problems
in Social Security programs. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to another
agency in accordance with approved routine uses, which include, but are not limited to the
following:
1. To comply with Federal laws regulating the release of information from Social
Security records (e.g., to the Government Accountability Office and the Department
of Veterans’ Affairs);
2. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State and local level; and,
3. To facilitate statistical research, audit, and investigatory activities necessary to assure
the integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. We use the information from these programs to establish or verify a person’s
eligibility for federally-funded or administered benefit programs and for repayment, incorrect
payments or delinquent debts under these programs.
A complete use of routine uses for this information is available in our Privacy Act Systems of
Records Notices, 60-0059, Earnings Recording and Self-Employment Income System. This
notice, additional information regarding our programs and systems, are available online at
www.socialsecurity.gov or at any local Social Security office.