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14.SSA 821 - Work Activity Report

14.SSA 821 - Work Activity Report

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Published by: Henry Jacob Baker Jr on Nov 14, 2010
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ExplanationofEarnings:Weneedtoknowthisinformationbecause:
BlindNot Blind
NameofWageEarner(ifdifferentfromClaimantorBeneficiary)
FormApprovedOMBNo.0960-0059
SOCIALSECURITYADMINISTRATION
WORK ACTIVITY REPORT — EMPLOYEE
IDENTIFICATION-TOBECOMPLETEDBYSSAClaimantorBeneficiaryisReceiving:PARTI-TOBECOMPLETEDBYSSAPleaseusethisformtotellusaboutyourworksince1.2.ANSWERTHEQUESTIONSONTHISFORMANDRETURNITANDANYOTHERINFORMATIONABOUTYOURCLAIMTOTHESOCIALSECURITYOFFICETHATGAVE(ORSENT)YOUTHEFORM.PARTII-TOBECOMPLETEDBYPERSONSAPPLYINGFORORRECEIVINGBENEFITSYoushouldanswereachofthequestionsbelowasbestandwithasmanydetailsasyoucan.Thisinformationwillhelpusdecideifyoushouldgetorkeepgettingbenefits.Foranyquestionbelow,ifyouneedmorespace,useitem9,onpages5and6.Remembertowritethenumberofthequestionthatyouareansweringinitem9.1.HAVEYOUWORKEDSINCETHEDATESHOWNINITEM1OFPART1,ABOVE?2.Claimant or Beneficiary's SSN
--
Wage Earner's SSN
- -
NameofClaimantorBeneficiaryYES If you did work, go to item 3 and answer the rest of the questions and sign and date the form.NO If you did not work, but earnings were reported for you as shown in item 2 of Part I above, go to item 2 below.
Social Security Disability Insurance (SSDI) BenefitsBoth SSDI and SSI Disability BenefitsSupplemental Security Income (SSI) Disability BenefitsNeither SSDI or SSI Disability Benefits
Ifyouneedmorespace,useItem9.ThengotoItems8and10.Form
SSA-821-BK
(09-2009)
ef 
(09-2009
)
FormerlySSA-821-F4&SSA-3945-BKDestroyPriorEditions
1REPORTEDWORKOREARNINGSIfyoudidnotwork,butearningswerereportedforyouasshowninItem2ofPart1,explainwhatthepaywasfor.Forexample,sometimespayissickpay,vacationpayorholidaypaythatyouearned,orforworkthatyoudidbeforebecomingunabletoworkbecauseofyourcondition.Ifyoucan'texplaintheearningsreportedforyouoryoudon'trememberwhatthetotalearningsarefor,askyouremployer(s).Ifyour employer(s)cannothelpyou,askyourlocalSocialSecurityOfficetohelpyou.Date
 
3.TELLUSABOUTYOURWORKSINCETHEDATEINITEM1OFPART1ABOVE.(Ifyouarenotsureaboutsomethings,askyouremployertohelpyou.Ifyouneedmorespace,useItem9,onpages5and6.RemembertowritethenumberofthequestionthatyouareansweringinItem9.)Employer'sNameEmployer'sAddress(Includestreet,city,state,&ZIP)A.JobTitleNumberofHours(onaverage)WorkedSupervisor'sNameCheckeachblockbelowthatistrueforthiswork:Istoppedworkingwithin6months,orIreducedmyworkhoursandearningswithin6months,orwithin6monthsIhadtochangethetypeofworkIwasdoing(e.g.,Youwereaplumberandchangedtolighterwork.)because:B.2PriorEmployer'sNameEmployer'sAddress(Includestreet,city,state,&ZIP)JobTitleNumberofHours(onaverage)WorkedSupervisor'sNameCheckeachblockbelowthatistrueforthiswork:Istoppedworkingwithin6months,orIreducedmyworkhoursandearningswithin6months,orwithin6monthsIhadtochangethetypeofworkIwasdoing(e.g.,Youwereaplumberandchangedtolighterwork.)because:Form
SSA-821-BK
09-2009
ef(
09-2009Per WeekPer DayPer WeekPer DaySupervisor'sTelephoneNumber 
(Include area code)
 
Supervisor'sTelephoneNumber 
(Include area code)
 
Starting Hourly Pay Current or Ending PayStarting Hourly Pay Current or Ending Payof my medical condition.special conditions at work related to my medical condition that allowed me to work were removed.I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)of my medical condition.special conditions at work related to my medical condition that allowed me to work were removed.I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)DateWorkEndedDateWorkStartedDateWorkEndedDateWorkStarted
 
SPECIALWORKCONDITIONS-Do(Did)yougetspecialhelpon-the-joborextrapayinanyofthejobsthatyoutoldusaboutinItem3?SincethedateyoustartedworkingonorafterthedateshowninItem1ofPart1,above,havetherebeenanymonthsduringwhichyouearnedover$200permonththrough12/2000orover$530beginning01/2001(beforeanythingwaswithheld;e.g.,taxes)?5.I needed and got special help from other I was given special equipment or was given I worked irregular hours or took frequent rest periods.I worked in a sheltered work center.I was allowed to work at a lower standard of I was hired through a special program for training or I worked for a relative or friend.3C.PriorEmployer'sNameEmployer'sAddress(Includestreet,city,state,&ZIP)JobTitleNumberofHours(onaverage)WorkedSupervisor'sNameCheckeachblockbelowthatistrueforthiswork:Istoppedworkingwithin6months,orIreducedmyworkhoursandearningswithin6months,orwithin6monthsIhadtochangethetypeofworkIwasdoing(e.g.,Youwereaplumberandchangedtolighterwork.)because:
 
Form
SSA-821-BK
09-2009
ef(
09-2009No (Go to Item 5.)Yes (Tell us which month and year and the amount you earned that month in the chart below. If you need morePer WeekPer Dayspace, use Item 9, on pages 5 and 6. Remember to write the number of the question that you are answering in Item 9.)about any other special condition(s) or help that you got on a job.workers in doing my job.work that was suited to my condition.productivity.I was given a job based on my past services to anemployer.therapy (e.g., vocational rehabilitation, supportedemployment). 4. MONTH/YEARAMOUNTMONTH/YEARAMOUNTMONTH/YEARAMOUNTNo (Go to Item 6.)Yes Check all of the boxes that are true for you and tell us for which job(s) you received that help and tell usSupervisor'sTelephoneNumber 
(Include area code)
Starting Hourly Pay Current or Ending Payof my medical condition.special conditions at work related to my medical condition that allowed me to work were removed.I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)DateWorkEndedDateWorkStarted$$$$$$$$$$$$

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