Form Ssa-820-Bk - Work Activity Report - Self-Employment Page 4
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4. In the space below, show each month you worked in your business, the net earnings, and if you worked 45 hours or more.
Date Worked
Worked more than 45
Date Worked
Worked more than 45
Net Earnings
Net Earnings
MM/YYYY
hours per month?
MM/YYYY
hours per month?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If you need more room for your answers, go to the Remarks section.
5. Please attach all of your self-employment tax returns (including Schedule C & SE) since the DATE shown in the
Identification section.
I have ENCLOSED my Tax Returns. Go to Question 6.
I DO NOT have Tax Returns. For any years that you DO NOT have tax returns, use the chart below to tell us
about your total annual gross and net self-employment income.
Year (YYYY)
Net
Year (YYYY)
Gross
Gross
Net
$
$
$
$
$
$
$
$
6. Has anyone besides yourself had management responsibilities for this business (i.e., a partner, employee, relative, or
helper) since the DATE shown in the Identification section?
NO. Go to Question 7.
YES. Complete the questions below.
•
How many hours per month (on average) does or did the other person(s) spend
Hours per month
on management duties
•
How many hours per month (on average) do or did you spend on management
Hours per month
duties?
•
Please tell us what duties you and the other person performed below.
Form SSA-820-BK (04-2012) ef (04-2012)
Page 2
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Parent category: Business