Work Activity Report - Self-Employment (Telephone)

Form SSA-820-BK (XX-XXXX) UF
Discontinue Prior Editions

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OMB No. 0960-0598

Social Security Administration
Retirement, Survivors, and Disability Insurance
Important Information

Date:
BNC #:

We are writing to you because we believe you may have recent self-employment work activity and we
need to know more about this work activity.
One of Social Security's top priorities is to support the efforts of applicants and beneficiaries with
disabilities who are or who want to work. The Social Security Disability Insurance (SSDI) and
Supplemental Security Income (SSI) programs include several employment support provisions
commonly referred to as work incentives, or special rules that help you to receive, or continue to
receive benefits even if you are working. We need more information to see if any of these incentives
apply to you. If you are just now applying for disability benefits, the information you provide helps us
decide if you can receive benefits. If you are currently receiving disability benefits, the information you
provide helps us decide if your benefits can continue.
Information about Work and Earnings
Our records show that you may have self-employment income.
Common types of self-employment include:
•
•
•
•
•

Owning your own business, Sole Proprietorship/Corporation
Owning a business with another person, Business Partnership
Independent Contractor
Freelancing for another business
Gig Work, such as:
o Ride share driving services
o Food delivery services
o Internet content creator/influencer
o Musicians/Photographer/Artists

• Any job for which one receives form 1099-NEC instead of form W2 for IRS tax filing purposes.

Form SSA-820-BK (XX-XXXX) UF

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The information we ask for includes:
• Self-Employment History: This includes the dates you worked, net earnings from selfemployment, and any pay you received working as an independent contractor for another person
or company (e.g., driver, delivery, consulting, etc.).
• Special Self-employment Conditions: If you receive free help in your business, we may be
able to deduct the reasonable value of that help from your net income. Also, if another person,
agency or business provides items or services to you, free of charge, we may be able to deduct
the reasonable value of those items or services from your net income.
• Work Expenses related to your disability: If you are self-employed and have a disability, you
may need certain items or services to assist you (e.g., co-pays for prescription drugs, medical
device expenses, special transportation, counseling fees, expenses related to a service animal,
etc.) Note: Do not include anything that you will include as a business expense on your
annual tax return.
Our records show that the following self-employment income was reported for you.
Income Reported for You
Self-Employment

Year

Yearly Income

We may ask for proof of any of the information you provide.
What You Need To Do
Please complete and return this form within 15 days. It is important to fill out the form carefully and
completely even if you receive additional forms requesting authorization to obtain wage and
employment information from payroll data providers. If you do not return this form, we may make our
decision based on the information we have in our records.
For More Information
Please read the 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
available online at www.ssa.gov/pubs/EN-05-10095.pdf. You may also visit www.choosework.ssa.gov
or contact the Ticket to Work Help Line at 1-866-968-7842 (TTY 1-866-833-2967) to learn more about
work incentives and find service providers who can explain how work can affect your benefits.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/report or call the Inspector
General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

Form SSA-820-BK (XX-XXXX) UF

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Need more help?
1. Visit www.ssa.gov for fast, simple, and secure online service.
2. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing,
call TTY 1-800-325-0778. Please mention this letter when you call.
3. You may also call your local office at
.

How are we doing? Go to www.ssa.gov/feedback to tell us.

Social Security Administration

Enclosures:
Pre-addressed Envelope

Form SSA-820-BK (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0598

Work Activity Report - Self-Employment
IDENTIFICATION
Name of Claimant or Beneficiary

BNC# or SSN

Blind
Not Blind

We have information that you have been self-employed since your disability began, since your date of entitlement to
benefits, or since your last work review. Please answer the questions below. This will help us decide if you can receive or
continue to receive benefits, and if work incentives apply to you. Please provide information since the date shown below.”
If a date is not shown, please provide information for
the last two years.

Date: (to be completed by SSA)

SELF-EMPLOYMENT INFORMATION
1. Have you engaged in any self-employment activity or had any self-employment income since the date shown in the
IDENTIFICATION section, or within the last two years? (check one)

NO. If you were not self-employed, go to question 2.
YES. If you have been self-employed, go to the SELF-EMPLOYMENT INFORMATION section, question 3A.
2. The information we have may include reports of other types of income for you even if you are not self-employed. Other
types of income include income after your business closed, income from sale of the business, and disability pay/
insurance. We may ask for verification of the income that has been reported.
Did you receive other types of income since the date shown above or within the last two years?
NO. If you did not receive any other type of income and have not worked, please specify any possible source
of reported income below, then go to the SIGNATURE section, complete, sign and return the form.
YES. Tell us about that income below and then go to the SIGNATURE section, complete, sign and return the
form.
Please use this space to tell us more about the income you received (type of income, source of income, amount, date(s)
paid, etc.)

3. Please tell us about your self-employment since the date shown in the IDENTIFICATION section, or within the last two
years. If we have not already received proof of your income, we may ask you to submit it.
Name of Business (if applicable)
Telephone # (include area code)

Mailing address

City

State ZIP Code

Fax # (include area code)

Primary Product or Service

Average Hours (hrs) Worked Per Month:
80 hrs or more per month

At least 45 but less than 80 hrs per month

Date Work Started (MM/DD/YYYY)

Less than 45 hrs per month

Date Work Ended (MM/DD/YYYY)
Still Working

Form SSA-820-BK (XX-XXXX) UF
Reason Work Ended (if applicable)

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Because of my disability

other reason(s)

What best describes your type of self-employment/business arrangement? (Check One)
Sole Owner

Partnership

Limited Liability Company (LLC)

Corporation

Independent Contractor

Gig Work*

Farm Landlord

Farm Tenant

Other (Please explain below)

*Examples of Gig Work include ride share driving services, food delivery services, internet content
creator or influencer and work as a musician, photographer, or artist.
Please use this space to tell us more about the business arrangement(s) you checked above (if other, type of business
arrangement.)

If you have another type of self-employment or business arrangement, please continue here. If not, you may skip this
section and go to question 4.
Name of Business (if applicable)
Telephone # (include area code)

Mailing address

City

State ZIP Code

Fax # (include area code)

Primary Product or Service?

Average Hours (hrs) Worked Per Month:
80 hrs or more per month

At least 45 but less than 80 hrs per month

Date Work Started (MM/DD/YYYY)

Less than 45 hrs per month

Date Work Ended (MM/DD/YYYY)
Still Working

Reason Work Ended (if applicable)
Because of my disability

other reason(s)

What best describes your type of self-employment/business arrangement? (Check One)
Sole Owner

Partnership

Limited Liability Company (LLC)

Corporation

Independent Contractor

Gig Work*

Farm Landlord

Farm Tenant

Other (Please explain below)

*Examples of Gig Work include ride share driving services, food delivery services, internet content
creator or influencer and work as a musician, photographer, or artist.
Please use this space to tell us more about the business arrangement(s) you checked above (if other, type of business
arrangement.)

Form SSA-820-BK (XX-XXXX) UF

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4A. Please attach all your self-employment tax returns (including Schedule C & SE, 1099s, etc.) since the date shown in
the IDENTIFICATION section, or for the last two years.
I have ENCLOSED my Tax Returns.
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)

Gross

Net

$

$

$

$

$

$

$

$

4B. If you are currently self-employed, please provide an estimate of your expected income.
Year (YYYY)

Gross

Net

$

$

$

$

5A. Did anyone other than you have management responsibilities for any business shown in question 3 (i.e., a partner,
employee, relative, or helper) since the DATE shown in the IDENTIFICATION section, or within the last two years?
NO. Go to Question 6A.
YES. Go to question 5B
5B. If someone other than you had management responsibilities for any business shown in question 3, please provide the
following information:
Business name as shown in question 3:

Other individual's name(s):

Their relationship to you:

Hours per month THEY had management responsibilities
(average):

Hours per month YOU had management responsibilities
(average):

Other individual's address:

Phone: (include area code)

Form SSA-820-BK (XX-XXXX) UF
Business name as shown in question 3:

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Other individual's name(s):

Their relationship to you:

Hours per month THEY had management responsibilities
(average):

Hours per month YOU had management responsibilities
(average):

Other individual's address:

Phone: (include area code)

Please use this space to tell us what duties you and the other individual performed below.

WORK INCENTIVES
6A. We may not count short periods of work (6 months or less) when we decide if you are eligible for benefits.
For any work that you told us about in the SELF-EMPLOYMENT INFORMATION section, did you make any changes
to your work due to your disability, or due to the removal of special conditions that allowed you to work?
NO. Go to Question 7A.
YES. Go to Question 6B.
6B. Mark any that apply, provide requested information, then go to question 7A.
I stopped working within 6 months or less due to my disability, or due to the removal of special conditions that
allowed me to work.
I changed to fewer hours of work or less earnings within 6 months or less due to my disability or due to the
removal of special conditions that allowed me to work.
I changed to a lighter or easier type of work due to my disability, or due to the removal of special conditions that
allowed me to work.
For any items checked above, please provide:
Date(s) of any Change:
Please use this space to tell us details about changes in your work activity due to your disability, or due to the removal of
special conditions that allowed you to work. Please include information about the special conditions that were removed.

Form SSA-820-BK (XX-XXXX) UF
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7A. We may be able to deduct certain expenses from your net earnings from self-employment before we decide if you are
eligible to receive or continue to receive benefits. Deducting expenses may help you become eligible for a benefit or
may increase the amount of a benefit to which you are already eligible. The expenses must be for items or services
that you pay for, that are needed because of your disability, and that are needed for you to work. The expenses
must be paid for out of pocket. We cannot count expenses that Medicare, Medicaid, an insurance company, or
another person paid or will pay back to you. Also, do not include any expenses, including business expenses, that you
will claim as an expense on your tax return filed with the Internal Revenue Service (IRS).
Examples of allowable expenses include medicines or co-pays, medical devices or procedures, special
transportation, special telephone or other equipment, service animal, attendant care, or special equipment if
you are blind, etc.
Did you spend any of your own money for items or services related to your disability that you needed for you to work?
NO. Go to SIGNATURE section, complete, sign and return the form.
YES. Go to question 7B.
For each expense, we may ask you for proof of payment, that you needed the item or service because of an
impairment(s) being treated by a healthcare provider, and how it helps you do your job.
7B. Please, use this section to tell us about the item(s) or service(s), the date(s) you purchased them and what they cost.
You should also tell us about recurring expenses.
Describe Item or Service

Cost per (day, week, month, or year)

Date Paid
(MM/YYYY-MM/YYYY)

Recurring
Expense
Y/N

Example: Medication

$25 per month

01/2024 - 02/2024

Y

$

per

$

per

$

per

Please use this space to tell us more about additional expenses or to provide additional information about the expenses
listed above.

8. When we determine your countable income, we may be able to deduct from your net income any business expenses
which were incurred and paid by another person or agency.
Examples include business related rent, supplies, inventory, purchase or repair of equipment, or an
employee or helper that works for you for free.
Has any person or organization (i.e., Vocational Rehabilitation or other State or local agency) contributed to or paid for
business expenses or provided any free help, items or services related to your business since the date shown in the
IDENTIFICATION section?
NO. Please go to SIGNATURE section, complete, sign and return the form.
YES. Please explain below.

Form SSA-820-BK (XX-XXXX) UF
Describe Contribution

Value of Contribution per
(day, week, month, or year)

Example: Rent

$1,000 per month
$

per

$

per

$

per

Name(s) of contributor:

Address:

Please use this space to tell us any additional contributions provided by others.

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Continuing
Date Paid
Expense
(MM/YYYY-MM/YYYY)
Y/N
01/2024 - Present

Y

Phone (including area code):

Form SSA-820-BK (XX-XXXX) UF

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Signature
I authorize any employer, agency, or other organization to disclose to the Social Security Administration or the State
agency that may determine or review my entitlement to disability benefits, any information about my physical and/or
mental condition or my work.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives
a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a
crime and may be sent to prison, or may face other penalties, or both.
Signature of Claimant, Beneficiary or Representative Payee

Date

Area Code and Telephone Number

Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route) City

State

ZIP Code

If this statement is signed with a mark (e.g., X), two individuals who know the person making the statement must
witness the signature and sign below, giving their full addresses and telephone numbers.
1. Signature of Witness

Date

Area Code and Telephone Number

Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route) City

2. Signature of Witness

Date

State

ZIP Code

Area Code and Telephone Number

Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route) City

State ZIP Code

Privacy Act Statement
Collection and Use of Personal Information
Sections 223(d) and 1633 of the Social Security Act, as amended, allow us to collect your information
or the information you are submitting on behalf of another, which we will use to determine benefit
eligibility. Providing the information is voluntary, but not providing all or part of the information may
prevent us from making an accurate determination on eligibility. As law permits, we may use and
share the information you submit, including with other Federal agencies, contractors, and others, as
outlined in the routine uses within System of Records Notices 60-0059 and 60-0089, available at
www.ssa.gov/privacy. The information you submit may also be used in computer matching programs
for Federal benefits eligibility and to recoup debts under these programs.

Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of
the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display
a valid Office of Management and Budget (OMB) control number. We estimate that it will take about
30 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments regarding this burden estimate or any other aspect of this collection, including
suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.