Form SSA-766 Statement of Self-Employment Income

Form SSA-766 (04-2021) UF
Discontinue Prior Editions
Social Security Administration

Page of
OMB No. 0960-0046

Statement of Self-Employment Income
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 fromself-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 selfemployment income and does not relieve the self-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?

Yes

No

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:

Signature of self-employed person or where self-employed person is deceased or
incompetent, of person having knowledge of the facts.

Form SSA-766 (04-2021) UF

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Privacy Act Statement
Collection and Use of Personal Information

See Revised
Privacy Act
Sections 205(a) and 205(c)(2) of the Social Security Act, as amended, allow us to
collect this information.
Statement
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent an accurate and timely decision on your claim.
We will use the information to determine your eligibility for benefits. We may also share your information for
the following purposes, called routine uses:
• To officers and employees of Federal, State or local agencies upon written request in accordance
with the Internal Revenue Code (IRC) U.S.C. 6103(1)(7)), tax return information (e.g., information
with respect to net earnings from self-employment, wages, payments of retirement income which
have been disclosed to the Social Security Administration, and business and employment
addresses) for purposes of, and to the extent necessary in, determining an individual's eligibility for,
or the correct amount of, benefits under certain programs listed in the IRC; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the 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, as published in the Federal Register (FR) on
January 11, 2006 at 71 FR 1819, and 60-0089, entitled Claims Folders System, as published in the FR on
April 1, 2003 at 68 FR 15784. Additional information and a full listing of all our SORNs are available on our
website at https://www.ssa.gov/privacy.
See Revised PRA
Statement
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. We estimate
that it will take about 5 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.