Form Ssa-820-Bk - Work Activity Report - Self-Employment Page 7
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8Claim #:
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.
Signature
I authorize any employer, agency, or other organization to disclose to the Social Security Administration or the State
agency that may determine or review my entitlement to disability benefits, any information about my physical and/or mental
condition(s) or my work.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who
knowingly gives a false or misleading statement about a material fact in this information, or causes someone else
to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
Signature of Claimant, Beneficiary or Representative
Date
Area Code and Telephone Number
Mailing address
City
State
ZIP
If this statement is signed with a mark (e.g. X), two witnesses to the signing who know the person making the statement
must sign below, giving their full addresses and telephone numbers.
1. Signature of Witness
Date
Area Code and Telephone Number
Mailing address
City
State
ZIP
2. Signature of Witness
Date
Area Code and Telephone Number
Mailing address
City
State
ZIP
Form SSA-820-BK (04-2012) ef (04-2012)
Page 5
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Parent category: Business