Form SSA-821-BK Work Activity Report- Employee

Form SSA-821-BK (XX-XXXX) UF
Discontinue Prior Editions

Page 1 of 12
OMB No. 0960-0059

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

Date:
BNC#:

We are writing to you because we need to know more about your work. Please tell us about your
. We will use this information to decide if you can receive or continue
work since
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

Year

Earnings

Form SSA-821-BK (XX-XXXX) UF

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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 at www.ssa.gov/pubs/10095.html online.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov/report or call the Inspector
General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).
If You Have Questions
If you have any questions, or need help completing the form:
• Visit our website at www.ssa.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 or its territories:
○ If you are in Canada, visit www.ssa.gov/foreign/canada.htm to find the office that
services your area.
○ Contact your nearest Federal Benefits Unit (FBU). Visit www.ssa.gov/foreign/foreign.htm
for a list of FBU's.
○ Write to the Social Security Administration at:
P.O. Box 17769
Baltimore, Maryland, 21235-7769
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 (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration

Page 3 of 12
OMB No. 0960-0059

Work Activity Report - Employee
Identification - To Be Completed by SSA
Name of Claimant or Beneficiary

BNC#

Blind
Not Blind

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.
Date Worked
Type of Payment
Name and Address of Payer
Amount
(MM/YYYY-MM/YYYY)
Example

ABC Company
123 Any Street
Your Town, MD 54321

$100 per day, week,
month, or year

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)

01/2000 - 02/2000

Form SSA-821-BK (XX-XXXX) UF

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BNC#:

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.
Supervisor's Telephone No.
Current or Most Recent Employer's Name
Supervisor's Name
(include area code)
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
$

Hours Worked per
Week (on average)

per

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
MM/YYYY

Amount

Date Earned
MM/YYYY

Date Earned
MM/YYYY

Amount

Amount

$

$

$

$

$

$

$

$

$

$

$

$

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

Supervisor's Telephone No.
(include area code)

Supervisor's Name

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
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

$

$

$

$

$

$

$

$

$

$

$

$

Form SSA-821-BK (XX-XXXX) UF

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BNC#:

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

Supervisor's Telephone No.
(include area code)

Supervisor's Name

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
MM/YYYY

Amount

Date Earned
MM/YYYY

Date Earned
MM/YYYY

Amount

Amount

$

$

$

$

$

$

$

$

$

$

$

$

If you have more employers, go to Additional Employment Information.
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):

Type of Payment

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

$

per

$

per

$

per

Form SSA-821-BK (XX-XXXX) UF

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BNC#:

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.

Date
(MM/YYYY to
MM/YYYY)

Please Describe

Form SSA-821-BK (XX-XXXX) UF

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BNC#:

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)

Stopped working

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

Reduced my work
hours

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

Reduced my earnings

Special conditions that allowed me to work
were removed
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 (XX-XXXX) UF

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BNC#:

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 (XX-XXXX) UF

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BNC#:

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.
Area Code and
Signature of Claimant, Beneficiary or Representative
Date
Telephone Number
Mailing Address (Number and Street, Apt. no., P.O. Box, or Rural Route) City

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) City

2. Signature of Witness

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

Area Code and
Telephone Number
State ZIP Code

Date

Area Code and
Telephone Number
State ZIP Code

Form SSA-821-BK (XX-XXXX) UF

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Privacy Act Statement
Collection and Use of Personal Information
Sections 223(d) and 1633 of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent an accurate and timely decision on any claim filed or could result in an overpayment of benefits.
We will use the information to make a determination of eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•

To employers or former employers for correcting or reconstructing earnings records and for
Social Security tax purposes only; and

•

To contractors and other Federal agencies, as necessary, for the purpose of assisting Social
Security Administration in the efficient administration of its programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person's eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN)
60-0059, entitled Earnings Recording and Self-Employment Income System, as published in the Federal
Register (FR) on January 11, 2006, at 71 FR 1819, 60-0320, entitled Electronic Disability Claim File, as
published in the FR on December 22, 2003, at 68 FR 71210, and 60-0330, entitled eWork, as published
in the FR on September 15, 2003, at 68 FR 54037. Additional information, and a full listing of all our
SORNs, is available on our website at www.ssa.gov/privacy.

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 (XX-XXXX) UF

Page 11 of 12
BNC#:
ADDITIONAL EMPLOYMENT INFORMATION
(Continuation from Page 5)

Employer's Name

Supervisor's Telephone No.
(include area code)

Supervisor's Name

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
$

Hours Worked per
Week (on average)

per

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
MM/YYYY

Amount

Date Earned
MM/YYYY

Date Earned
MM/YYYY

Amount

Amount

$

$

$

$

$

$

$

$

$

$

$

$

Employer's Name

Supervisor's Telephone No.
(include area code)

Supervisor's Name

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
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

$

$

$

$

$

$

$

$

$

$

$

$

Form SSA-821-BK (XX-XXXX) UF

Page 12 of 12
BNC#:
ADDITIONAL EMPLOYMENT INFORMATION
(Continuation from Page 5)

Employer's Name

Supervisor's Telephone No.
(include area code)

Supervisor's Name

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
$

Hours Worked per
Week (on average)

per

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
MM/YYYY

Amount

Date Earned
MM/YYYY

Date Earned
MM/YYYY

Amount

Amount

$

$

$

$

$

$

$

$

$

$

$

$

Employer's Name

Supervisor's Telephone No.
(include area code)

Supervisor's Name

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
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

Date Earned
MM/YYYY

Amount

$

$

$

$

$

$

$

$

$

$

$

$