Form SSA-821-BK Work Activity Report- Employee

Social Security Administration
Retirement, Survivors, and Disability Insurance
Important Information

FO Address:

Date:
Claim Number:

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

Form SSA-821-BK (04-2012) ef (04-2012)

Year

Earnings

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.
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 (04-2012) ef (04-2012)

Form Approved
OMB No. 0960-0059

SOCIAL SECURITY ADMINISTRATION

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(s) & 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

Amount

ABC Company
123 Any Street
Your Town, MD 54321

Date Worked
(MM/YYYY-MM/YYYY)

$100 per day, week, month, or
year

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

$

per

Other (Please explain)

Form SSA-821-BK (04-2012) ef (04-2012)
Destroy Prior Editions

Page 1

Claim #:
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
Area Code and Telephone Number Area Code and Fax Number
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
Date Earned
Date Earned
Amount
Amount
Amount
MM/YYYY
MM/YYYY
MM/YYYY
$

$

$

$

$

$

$

$

$

$

$

$

3B. If you do not have any more employers, go to Question 4.
Previous Employer's Name

Area Code and Telephone Number Area Code and Fax Number

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

$

$

$

$

$

$

$

$

$

$

$

Form SSA-821-BK (04-2012) ef (04-2012)

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Claim #:
3C. If you do not have any more employers, go to Question 4.
Previous Employer's Name

Area Code and Telephone Number Area Code and Fax Number

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

$

$

$

$

$

$

$

$

$

$

$

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):

Payment or Item

Employer Name

Amount or Estimate of Value

Date Received
(MM/YYYY-MM/YYYY)

Example: Sick Pay

ABC Company

$100 per day, week, month, or
year

01/2000 - 02/2000

Form SSA-821-BK (04-2012) ef (04-2012)

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$

per

$

per

$

per

Claim #:
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

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 (04-2012) ef (04-2012)

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Date
(MM/YYYY to
MM/YYYY)

Please Describe

Claim #:
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
My physical and/or mental condition(s)
Special conditions that allowed me to
work were removed

Stopped working

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

Reduced my work hours

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

Reduced my earnings

Other reasons (please explain in 6B)
My physical and/or mental condition(s)
Changed to a lighter or
easier type of work

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 (04-2012) ef (04-2012)

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Claim #:
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
(MM/YYYY-MM/YYYY)

Example: Service animal

$100 per day, week, month, or year

01/2000 - 02/2000

$

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 (04-2012) ef (04-2012)

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Claim #:

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

Mailing address (Number and Street, Apt. no., P.O. Box, or Rural Route)

City

Area Code and Telephone Number
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

Mailing address (Number and Street, Apt. no., P.O. Box, or Rural Route)

2. Signature of Witness

Date

Mailing address (Number and Street, Apt. no., P.O. Box, or Rural Route)

Form SSA-821-BK (04-2012) ef (04-2012)

City

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City

Area Code and Telephone Number
State

ZIP Code

Area Code and Telephone Number
State

ZIP Code

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act, as amended, authorize us to collect this
information. The information on this form is needed by Social Security to make a decision on the named
claimant's claim. While giving us the information on this form is voluntary, failure to provide all or part of the
requested information could prevent an accurate or timely decision on the named claimant's claim. We
generally use the information you supply for the purpose of making decisions regarding claims. 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 enable a third party or agency to assist Social Security in establishing rights to Social Security benefits
and/or coverage;
(2) to comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and the Department of Veterans Affairs);
(3) to make determinations for eligibility in similar health and income maintenance programs at the Federal,
State, and local level; and
(4) to facilitate statistical research, audit, or investigative activities necessary to assure the integrity 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. Information from these
matching programs can be used to establish or verify a person's eligibility for Federally-funded or
administered benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notice entitled,
Earnings Record and Self-Employment Income System, 60-0059. The notice, additional information
regarding this form, and information regarding our system and programs, are available on-line at
www.socialsecurity.gov or at any local Social Security office.

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 (04-2012) ef (04-2012)

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Claim #:
ADDITIONAL EMPLOYMENT INFORMATION
(Continuation from Page 3)
Employer's Name

Area Code and Telephone Number Area Code and Fax Number

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

$

$

$

$

$

$

$

$

$

$

$

Employer's Name

Area Code and Telephone Number Area Code and Fax Number

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

$

$

$

$

$

$

$

$

$

$

$

Form SSA-821-BK (04-2012) ef (04-2012)

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Claim #:
ADDITIONAL EMPLOYMENT INFORMATION
(Continuation from Page 3)
Employer's Name

Area Code and Telephone Number Area Code and Fax Number

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

$

$

$

$

$

$

$

$

$

$

$

Employer's Name

Area Code and Telephone Number Area Code and Fax Number

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

$

$

$

$

$

$

$

$

$

$

$

Form SSA-821-BK (04-2012) ef (04-2012)

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