Form SSA-821-BK Work Activity Report - Employee

What Is Form SSA-821-BK?

Form SSA-821-BK, Work Activity Report - also known as SSA Form 821-BK- is a form used for reporting an individual's working activity to the Social Security Administration (SSA). This form is necessary to determine the individual's eligibility for disability benefits.

This form requires information only about working activity after the alleged onset date (AOD). AOD is the day the individual claims to be unable to work because of a disability. The latest version of the form was issued by the SSA in January 2019. An SSA-821-BK fillable form is available for download and digital filing below.

Why Did I Get Form SSA-821-BK?

The SSA mailed you the SSA Work Activity Report because you receive disability insurance benefits. The administration received information about your working activity after the AOD and it requires information about your work to make sure that you are still eligible for the benefits. The cover page of Form SSA-821-BK contains a reason for mailing the form to you.

If you have been doing any kind of work and earn any amount of money, you should file the report.

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Form SSA-821-BK (01-2019) UF
Page 1 of 12
Discontinue Prior Editions
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
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 (01-2019) UF
Page 1 of 12
Discontinue Prior Editions
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
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 (01-2019) UF
Page 2 of 12
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.
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.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 (01-2019) UF
Discontinue Prior Editions
Page 3 of 12
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 & 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
Type of Payment
Name and Address of Payer
Amount
(MM/YYYY-MM/YYYY)
ABC Company
$100 per day, week,
Example
123 Any Street
01/2000 - 02/2000
month, or year
Your Town, MD 54321
$
per
Back Pay
Vacation Pay
$
per
$
per
Holiday Pay
$
per
Bonus or Commission
$
per
Royalties
$
per
Sick Pay
Disability Pay
$
per
$
per
Insurance Payment
$
per
Workers Comp
Other (Please explain)
$
per
Form SSA-821-BK (01-2019) UF
Page 4 of 12
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
Date Work Ended (if ended)
Rate of Pay
Hours Worked per
Still working
(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
$
$
$
$
$
$
$
$
$
$
$
$
3B. If you do not have any more employers, go to Question 4.
Supervisor's Telephone No.
Previous Employer's Name
Supervisor's Name
(include area code)
Mailing Address
City
State ZIP Code
Job Title and Type of Work
Date Work Started
Date Work Ended (if ended)
Rate of Pay
Hours Worked per
Still working
(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 (01-2019) UF
Page 5 of 12
BNC #:
3C. If you do not have any more employers, go to Question 4.
Supervisor's Telephone No.
Previous Employer's Name
Supervisor's Name
(include area code)
Mailing Address
City
State ZIP Code
Job Title and Type of Work
Date Work Started
Date Work Ended (if ended)
Rate of Pay
Hours Worked per
Still working
(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
$
$
$
$
$
$
$
$
$
$
$
$
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
Other (Please explain):
Date Received
Type of Payment
Employer Name
Amount or Estimate of Value
(MM/YYYY-MM/YYYY)
$100 per day, week,
Example: Sick Pay
ABC Company
01/2000 - 02/2000
month, or year
$
per
$
per
$
per

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How to Fill out Form SSA-821-BK?

Instructions for Form SSA-821-BK are as follows:

  1. Provide your name and social security number. Indicate if you are visually impaired. Enter your claim number and Beneficiary Identification Code (BIC). Enter the date you started your work activity. This may be either the AOD, date of entitlement or last determination date;
  2. Question 1. Indicate, whether you received any income or wages since the date stated above. If you answered negatively, go to Question 2. If you answered positively, go to Question 3;
  3. Question 2. Report types of income you received from the stated date. If you received any income from the list, check the box, enter the name and the address of the payer, the amount of the payment and the time period of the payment;
  4. Question 3A. Provide information about your work activity from the date you stated in the identification section. Enter the name of the current or most recent employer. Provide the name and phone number of the supervisor. Enter the mailing address of your employer. Enter your job title and type of work. State the date your employment started and ended. If you are still working, leave the date box blank and check the "Still working" box. Provide your pay rate and working hours;
  5. Attach copies of your pay stubs or a wage-print. If these papers do not cover the whole employment period, provide information about your income in the table;
  6. Question 3B. Provide information about all your employers. If the provided space is not enough, use the Remarks section;
  7. Question 4. Indicate, whether you received any payment or benefits additional to your wages. If you did, specify the type of benefits or payment and provide information about it in the table. Enter the type of payment, the name of the employer, amount of payment or estimated value of the benefit and the date it was received;
  8. Question 5. Indicate, whether you worked under special conditions listed in the table. If you did, specify the condition, provide the name of the employer, the date these conditions took place and describe them;
  9. Question 6A. Indicate, if there were changes in your employment. Specify the type of change, name of the employer, date when the change took place and indicate a reason for that change;
  10. Question 6B. Provide additional information about the changes listed above, if necessary.
  11. Question 7. Indicate, whether you covered the cost of items or services related to your condition from our own funds and if you were not reimbursed. If you did, specify, what you paid for, the amount you paid and the date you made this payment;
  12. Sign and date the form. Provide your mailing address. If the form is signed by the X mark, it must contain two signatures of witnesses.

Where to Send Form SSA Form 821-BK?

If the SSA mailed the form to you, return the completed form to the address shown on the envelope. If you are filing the form yourself, send it to your local SSA office after you received a payment. The mailing address of the office can be found on the SSA website. You should do this within 15 days after receiving the form.

What Happens if My SSA-821 Form Is a Couple of Days Late?

If the SSA does not receive Form SSA-821-BK on time, it will make a decision regarding your eligibility based on the information it has. It may also contact your employer and receive the information from them.

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