Form Ssa-821-Bk - Work Activity Report - Employee Page 3
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12Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0059
Work Activity Report - Employee
Identification - To Be Completed by SSA
Name of Claimant or Beneficiary
Claimant or Beneficiary's Own SSN
Blind
Not Blind
Claim Number(s) & BIC
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.
If you need more room for your answers, go to the Remarks section at the end of the form.
1. Have you had any employment income or wages since the DATE shown above in the Identification section? (check one)
NO. If you did not work but income was reported for you, go to Question 2.
YES. Go to Question 3.
2 . If you did not work, other types of income may have been reported for you. Please complete the information below. We
may ask you for proof of this income. When you are finished, go to Question 7.
Date Worked
Amount
Type of Payment
Name and Address of Payer
(MM/YYYY-MM/YYYY)
ABC Company
$100 per day, week, month, or
01/2000 - 02/2000
123 Any Street
Example
year
Your Town, MD 54321
Back Pay
$
per
Vacation Pay
$
per
Holiday Pay
$
per
Bonus or Commission
$
per
Royalties
$
per
Sick Pay
$
per
Disability Pay
$
per
Insurance Payment
$
per
Workers Comp
$
per
Other (Please explain)
$
per
Page 1
Form SSA-821-BK (04-2012) ef (04-2012)
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