Form Ssa-821-Bk - Work Activity Report - Employee Page 11
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ADDITIONAL EMPLOYMENT INFORMATION
(Continuation from Page 3)
Employer's Name
Area Code and Telephone Number Area Code and Fax Number
Mailing address
City
State
ZIP Code
Job Title and Type of Work
Hours Worked per
Date Work Started
Date Work Ended (if ended)
Still working Rate of Pay
Week (on average)
(MM/DD/YYYY)
(MM/DD/YYYY)
$
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
$
$
$
$
$
$
$
$
$
$
$
$
Employer's Name
Area Code and Telephone Number Area Code and Fax Number
Mailing address
City
State
ZIP Code
Job Title and Type of Work
Hours Worked per
Date Work Started
Date Work Ended (if ended)
Still working Rate of Pay
Week (on average)
(MM/DD/YYYY)
(MM/DD/YYYY)
$
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 (04-2012) ef (04-2012)
Page 9
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