Form Ssa-820-Bk - Work Activity Report - Self-Employment Page 8
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8Privacy Act Statement
Collection and Use of Personal Information
Sections 223 and 1632 of the Social Security Act as amended [42 U.S.C. 423 and 1383a], authorize us to collect this
information. The information you provide will allow us to determine your eligibility for benefits. Your response is
voluntary. However, your failure to provide all or part of the requested information could prevent us from making an
accurate and timely decision on your claim and could result in the loss of benefits.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above.
However, we may use it for the administration and integrity of Social Security programs. We may also disclose
information to another person or to another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to
the Government Accountability Office, General Services Administration, National Archives Records
Administration, and the Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of
Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records
to the records kept by other Federal, State or local government agencies. Information from these matching agencies can
be used to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notice entitled, Earnings
Recording and Self-Employment Income System, 60-0059. The notice, additional information regarding this form, and
information regarding our system and programs, are available on-line at
or at any local Social
Security office.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0598.
We estimate that it will take about 30 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.
Form SSA-820-BK (04-2012) ef (04-2012)
Page 6
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Parent category: Business