Claim #:
3C. If you do not have any more employers, go to Question 4.
Previous 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
$
$
$
$
$
$
$
$
$
$
$
$
If you have more employers, go to the Remarks Section.
4. Do or did you get any other payment(s) or benefit(s) from an employer in addition to the regular pay shown in
Question 3?
NO. Go to Question 5.
YES. Please check all that apply below.
Sick Pay
Disability Pay
Vacation Pay
Tips
Bonus
Transportation
Car or Vehicle
Childcare
Meals
Room or Rent
(Please explain):
Other
Date Received
Amount or Estimate of Value
Payment or Item
Employer Name
(MM/YYYY-MM/YYYY)
$100 per day, week, month, or
Example: Sick Pay
ABC Company
01/2000 - 02/2000
year
$
per
$
per
$
per
Form SSA-821-BK (04-2012) ef (04-2012)
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