SSA-1458 Current Version

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.

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