How to Fill out Form SSA-821-BK?
Instructions for Form SSA-821-BK are as follows:
- 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;
- 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;
- 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;
- 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;
- 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;
- Question 3B. Provide information about all your employers. If the provided space is not enough, use the Remarks section;
- 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;
- 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;
- 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;
- Question 6B. Provide additional information about the changes listed above, if necessary.
- 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;
- 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.