SSA-3192 Current Version

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

Date:
Claim Number:

Beneficiary name
Address
City St ZIP
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 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-820-BK
(mm-yyyy)

If You Have Questions
If you have any questions, or need help completing the form:
 Visit us online at www.socialsecurity.gov. We can answer many of your general
questions online.
 Call us toll-free at 1-800-772-1213, or call your local field office at xxx-xxx-xxxx. If you
are deaf or hearing impaired, our TTY toll-free number is 1-800-325-0778. We can
answer most of your questions over the phone.
 Write or visit any Social Security office. The office that serves your area is located at:
Insert local FO address
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 the Social Security Administration, P.O. Box 17775, Baltimore, Maryland,
21235-7775, USA.
If you do call or visit an office, please have this letter with you. It will help us answer your
questions. Also, if you plan to visit an office, please call ahead to make an appointment. This
will help us serve you more quickly.
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.

District Manager

Enclosures:
----------------------Form(s): SSA-820-F4 or SSA- 821-BK
SSA Pub No. 05-10095
Pre-addressed Envelope

Form SSA-820-BK
(mm-yyyy)

Claim # 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
Please use this form to tell us about your work activity since (Insert alleged onset date, date of onset, 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 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

Example: Income after

ABC Company
123 Any Street,
Your Town, MD 54321

business stopped

Amount or Estimate of Value
$100 per day, week,
month, or year

Date Worked
(MM/YYYY - MM/YYYY)
01/2000 - 02/2000

$ __________per__________
$ __________per__________
3. Please tell us about your work since the DATE in the Identification section.
Type of Self-Employment or Name of Business

Area Code and Telephone Number

Mailing Address

City

Area Code and Fax Number
State

ZIP

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

Date Work Ended (If ended) (MM/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 (mm-yyyy)

Other (Please explain)

1

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?

Net Earnings

Date Worked
(MM/YYYY)

Worked more than 45
hours per month?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes
Yes
Yes

No
No
No

Yes
Yes

No
No

Yes
Yes

No
No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes
Yes

No
No

Yes
Yes

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)

Gross

Net

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?
• How many hours per month (on average) do or did you spend on management duties?
• Please tell us what duties you and the other person performed below.

Form SSA-820-BK (mm-yyyy)

2

Hours per month.
Hours per month.

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

Please Explain.

Date
(MM/YYYY)

Stopped Working

My hours reduced from _______ per _______
Reduced my work hours

to _______ per _______ because

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, the value of the contribution, and who provided
them below.

Form SSA-820-BK (mm-yyyy)

3

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.

Cost

Describe Item or Service
Example: Money spent for medicines

$100 per day, week,
month, or year

Date Paid
(MM/YYYY - MM/YYYY)

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 (mm-yyyy)

4

Claim #
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

City

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 with 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.

Form SSA-820-BK (mm-yyyy)

5

PAPERWORK REDUCTION ACT
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 30 minutes to read the
instructions, gather the necessary facts, and answer the questions. SEND THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is
listed under U.S. Government agencies in your telephone directory or you may
call Social Security at 1-800-772-1213. You may send comments on our time estimate
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.

Form SSA-820-BK (mm-yyyy)

6