Form SSA-B20-BK Work Activity Report - Self-employment

Form SSA-B20-BK is a U.S. Social Security Administration form also known as the "Work Activity Report - Self-employment". 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-B20-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 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
Year
Yearly Income
Form SSA-820-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 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
Year
Yearly Income
Form SSA-820-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-820-BK (04-2012) ef (04-2012)
Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0598
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.
Date Worked
Amount or Estimate of Value
Payment For
Name and Address of Payer
(MM/YYYY-MM/YYYY)
Example: Income
ABC Company
$100 per day, week, month, or
01/2000 - 02/2000
after business
123 Any Street
year
stopped
Your Town, MD 54321
$
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?
Average Number of
Date Work Started (MM/DD/YYYY)
Date Work Ended (if ended) (MM/DD/YYYY)
Still working
Hours Worked
Type of ownership arrangement? (Check one)
Sole Owner
Limited Liability Company (LLC)
Other (Please explain)
Corporation
Partnership
Farm Landlord
Farm Tenant
Form SSA-820-BK (04-2012) ef (04-2012)
Page 1
Destroy Prior Editions
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
Worked more than 45
Date Worked
Worked more than 45
Net Earnings
Net Earnings
MM/YYYY
hours per month?
MM/YYYY
hours per month?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
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
Year (YYYY)
Gross
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
Hours per month
on management duties
How many hours per month (on average) do or did you spend on management
Hours per month
duties?
Please tell us what duties you and the other person performed below.
Form SSA-820-BK (04-2012) ef (04-2012)
Page 2
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
My hours reduced from
per
to
per
because
Reduced my work hours
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)
Page 3

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