Form SSA-3192 Application and Statement

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 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.
Self-Employment

Form SSA-820-BK (04-2012) ef (04-2012)

Year

Yearly Income

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
your Social Security contact,
questions over the phone.

,at

. You may also call
. We can answer most

• 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-820-BK (04-2012) ef (04-2012)

Form Approved
OMB No. 0960-0598

SOCIAL SECURITY ADMINISTRATION

Work Activity Report - Self-Employment
Identification - To Be Completed by SSA

Name of Claimant or Beneficiary

Claimant or Beneficiary's Own SSN

Blind
Not Blind

Claim Number(s) & BIC
DATE

Please use this form to describe your work activity since (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.
YES. Go to QUESTION 3.

2 . If you did not work but income was reported for you, complete the information below. When you are finished, go to
Question 9.
Payment For

Name and Address of Payer

Amount or Estimate of Value

Example: Income
after business
stopped

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

$

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

Mailing address

City

State

ZIP

What is the primary product or service?
Date Work Started (MM/DD/YYYY)

Date Work Ended (if ended) (MM/DD/YYYY)

Still working

Average Number of
Hours Worked

Type of ownership arrangement? (Check one)
Sole Owner

Limited Liability Company (LLC)

Corporation

Partnership

Farm Landlord

Farm Tenant

Form SSA-820-BK (04-2012) ef (04-2012)
Destroy Prior Editions

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Other (Please explain)

Claim #:
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
MM/YYYY

Net Earnings

Worked more than 45
hours per month?
Yes
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Date Worked
MM/YYYY

Net Earnings

No
No
No
No
No
No
No
No
No
No
No

Worked more than 45
hours per month?
Yes
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
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) 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)

Net

Gross

$
$

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?
NO. Go to Question 7.
YES. Complete the questions below.

•
•
•

How many hours per month (on average) does or did the other person(s) spend
on management duties

Hours per month

How many hours per month (on average) do or did you spend on management
duties?

Hours per month

Please tell us what duties you and the other person performed below.

Form SSA-820-BK (04-2012) ef (04-2012)

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Claim #:
7. Since the DATE shown in the Identification section did you make any changes in your work activity due to your
physical and/or mental condition(s)?
NO. Go to Question 8.
YES. Please describe your changes below (Check all that apply below).
Type of change

Date (MM/DD/YYYY)

Please Explain

Stopped Working

Reduced my work hours

My hours reduced from

per

to

because

per

Changed to lighter or easier work

Other changes

8. Has any person or organization contributed to or paid for any business expenses or provided any free help, items, or
services related to your business since the DATE shown in the Identification section (For example: rent, supplies,
inventory, purchase, repair of equipment, or an employee or helper that works for you for free)
NO. Go to Question 9.
YES. Describe the expenses paid or items or services provided, their value of the contribution, and who
provided them below.

Form SSA-820-BK (04-2012) ef (04-2012)

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Claim #:
9. 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. Go to the next section.
YES. 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: Money spent for medicines

$100 per day, week, month, or year

01/2009 - 02/2009

$

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-820-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(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.
Signature of Claimant, Beneficiary or Representative

Date

Mailing address

City

Area Code and Telephone Number
State

ZIP

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

City

2. Signature of Witness

Date

Mailing address

Form SSA-820-BK (04-2012) ef (04-2012)

City

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Area Code and Telephone Number
State

ZIP

Area Code and Telephone Number
State

ZIP

Privacy Act Statement
Collection and Use of Personal Information
Sections 223 and 1632 of the Social Security Act as amended [42 U.S.C. 423 and 1383a], authorize us to collect this
information. The information you provide will allow us to determine your eligibility for benefits. Your response is
voluntary. However, your failure to provide all or part of the requested information could prevent us from making an
accurate and timely decision on your claim and could result in the loss of benefits.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above.
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 an 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, General Services Administration, National Archives Records
Administration, 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
to the records kept by other Federal, State or local government agencies. Information from these matching agencies 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
Recording 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 0960-0598.
We estimate that it will take about 30 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-820-BK (04-2012) ef (04-2012)

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