Form SSA-821-bk Work Activity Report - Employee

Form SSA-821-bk is a U.S. social security administration form also known as the "Work Activity Report - Employee". The latest edition of the form was released in April 1, 2012 and is available for digital filing.

Download an up-to-date fillable Form SSA-821-bk in PDF-format down below or look it up on the U.S. social security administration Forms website.

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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
Year
Earnings
Form SSA-821-BK (04-2012) ef (04-2012)
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
Year
Earnings
Form SSA-821-BK (04-2012) ef (04-2012)
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
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0059
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
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 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
Amount
Type of Payment
Name and Address of Payer
(MM/YYYY-MM/YYYY)
ABC Company
$100 per day, week, month, or
01/2000 - 02/2000
123 Any Street
Example
year
Your Town, MD 54321
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
Other (Please explain)
$
per
Page 1
Form SSA-821-BK (04-2012) ef (04-2012)
Destroy Prior Editions
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
Hours Worked per
Date Work Started
Date Work Ended (if ended)
Still working Rate of Pay
Week (on average)
(MM/DD/YYYY)
(MM/DD/YYYY)
$
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
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
Date Work Ended (if ended)
Still working Rate of Pay
Hours Worked per
(MM/DD/YYYY)
(MM/DD/YYYY)
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
Date Earned
Date Earned
Amount
Amount
Amount
MM/YYYY
MM/YYYY
MM/YYYY
$
$
$
$
$
$
$
$
$
$
$
$
Form SSA-821-BK (04-2012) ef (04-2012)
Page 2
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
Hours Worked per
Date Work Started
Date Work Ended (if ended)
Still working Rate of Pay
Week (on average)
(MM/DD/YYYY)
(MM/DD/YYYY)
$
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
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
(Please explain):
Other
Date Received
Amount or Estimate of Value
Payment or Item
Employer Name
(MM/YYYY-MM/YYYY)
$100 per day, week, month, or
Example: Sick Pay
ABC Company
01/2000 - 02/2000
year
$
per
$
per
$
per
Form SSA-821-BK (04-2012) ef (04-2012)
Page 3

Download Form SSA-821-bk Work Activity Report - Employee

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