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Get SSA-820-BK 2021-2024

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 Form SSA-820-BK 04-2012 ef 04-2012 Year Yearly Income For More Information Please read the enclosed pamphlet Working While Disabled. If you write please include a copy of this letter. It will help us answer your questions. Enclosures SSA Pub No. 05-10095 Pre-addressed Envelope Form Approved OMB No. 0960-0598 SOCIAL SECURITY ADMINISTRATION 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 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. 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. 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. 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 your Social Security contact questions over the phone. at. You may also call. We can answer most 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.

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