Form Ssa-821-Bk - Work Activity Report - Employee Page 10
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12Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act, as amended, authorize us to collect this
information. The information on this form is needed by Social Security to make a decision on the named
claimant's claim. While giving us the information on this form is voluntary, failure to provide all or part of the
requested information could prevent an accurate or timely decision on the named claimant's claim. We
generally use the information you supply for the purpose of making decisions regarding claims. However, we
may use it for the administration and integrity of Social Security programs. We may also disclose information
to another person or to another agency in accordance with approved routine uses, which include but are not
limited to the following:
(1) to enable a third party or agency to assist Social Security in establishing rights to Social Security benefits
and/or coverage;
(2) to comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and the Department of Veterans Affairs);
(3) to make determinations for eligibility in similar health and income maintenance programs at the Federal,
State, and local level; and
(4) to facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social
Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare
our records with records kept by other Federal, State, or local government agencies. Information from these
matching programs can be used to establish or verify a person's eligibility for Federally-funded or
administered benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notice entitled,
Earnings Record and Self-Employment Income System, 60-0059. The notice, additional information
regarding this form, and information regarding our system and programs, are available on-line at
or at any local Social Security office.
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. The OMB control number for this collection is 0960-0059.
We estimate that it will take about 40 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.
Form SSA-821-BK (04-2012) ef (04-2012)
Page 8
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