Form Ssa-820-Bk - Work Activity Report - Self-Employment Page 5
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8Claim #:
7. Since the DATE shown in the Identification section did you make any changes in your work activity due to your
physical and/or mental condition(s)?
NO. Go to Question 8.
YES. Please describe your changes below (Check all that apply below).
Type of change
Date (MM/DD/YYYY)
Please Explain
Stopped Working
My hours reduced from
per
to
per
because
Reduced my work hours
Changed to lighter or easier work
Other changes
8. Has any person or organization contributed to or paid for any business expenses or provided any free help, items, or
services related to your business since the DATE shown in the Identification section (For example: rent, supplies,
inventory, purchase, repair of equipment, or an employee or helper that works for you for free)?
NO. Go to Question 9.
YES. Describe the expenses paid or items or services provided, their value of the contribution, and who
provided them below.
Form SSA-820-BK (04-2012) ef (04-2012)
Page 3
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Parent category: Business