Form Ssa-821-Bk - Work Activity Report - Employee Page 8
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12Claim #:
7. Do or did you spend any of your own money for items or services related to your physical and/or mental condition(s)
that you needed in order to work and for which you did not get reimbursed? (For example; medicines or co-pays, medical
devices or procedures, Braille equipment, special telephone or equipment, service animal, attendant care, modifications to
a car used for work, or other special transportation.) We may ask you for proof of payment.
NO. I did not spend any of my own money for items or services related to my physical and/or mental condition.
YES. Please tell us what you paid below. Do not show any expenses that have been or will be paid by an
insurance company, other organization, or other person.
Date Paid
Cost
Describe Item or Service
(MM/YYYY-MM/YYYY)
Example: Service animal
$100 per day, week, month, or year
01/2000 - 02/2000
$
per
$
per
$
per
$
per
Remarks
Use this section to add any information you did not have space for in other parts of the form. Please show the
number of the question you are answering.
Form SSA-821-BK (04-2012) ef (04-2012)
Page 6
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