SSA-1398 Self-Employment Income (SEI) Form Beneficiary Quarterly

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Self-Employment Income (SEI) Form
Beneficiary Reported Self-Employment
BENEFICARY'S NAME:
BENEFICIARY'S
SOCIAL SECURITY NUMBER:
MONTH

GROSS INCOME

GROSS EXPENSES NET SELF-EMPLOYMENT
INCOME

I was actively involved in the operation of my business during the following months:

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 statement about a material
fact in this information, or causes someone else to do so, commits a crime and may be
subject to a fine or imprisonment.
BENEFICIARY'S SIGNATURE:

DATE:

BENEFICIARY'S ADDRESS (STREET ADDRESS, CITY, STATE, AND ZIP CODE):

BENEFICIARY'S TELEPHONE NUMBER
(WITH AREA CODE):

Form SSA-1398 (05-2016)

BENEFICIARY'S EMAIL:

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Privacy Act Statement
Collection and Use of Personal Information See Revised Privacy Act and
PRA Statements Attached.
Section 1148 of the Social Security Act authorizes us to collect this information. We will use the
information to monitor your progress in the Ticket to Work and Self-Sufficiency Program.
Furnishing us this information is voluntary; however, failing to provide all or part of the information
may prevent your successful participation in the Ticket to Work Program.
We rarely use the information you supply for any purpose other than what we state above, however,
we may use the information for the administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to private
entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notice, 60-0295, entitled Ticket-to-Work and Self-Sufficiency
Program Payment Database, and 60-0300, entitled Ticket-to-Work Program Manager (PM)
Management Information System. Additional information about this and other system of records
notices and our programs are available from our Internet website at www.socialsecurity.gov or at
your local Social Security office.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies.
Information from these matching programs can be used to establish or verify a person's eligibility for
federally funded or administered benefit programs and for repayment of incorrect payments or
delinquent debts under these programs.

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 control
number. We estimate that it will take about 3 minutes to read the instructions, gather the facts, and
answer the questions. SEND THE COMPLETED FORM TO: OPERATIONS SUPPORT MANAGER
(OSM) TICKET TO WORK, PO BOX 1433, ALEXANDRIA, VA 22313 OR FAX TO 703-893-4149.
You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.

Form SSA-1398 (05-2016)

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