Work Activity Report (Self-Employment) - In Office

Privacy Act Statement Template for Paper & Online Collections (SSA-820-BK In Office; SSA-820-BK Returned via Mail; SSA-820-APP)

Privacy Act Statement
Collection and Use of Personal Information

Sections 223(d) and 1633 of the Social Security Act, as amended, allow us to collect your information or the information you are submitting on behalf of another, which we will use to determine benefits eligibility. Providing the information is voluntary, but not providing all or part of the information may prevent an accurate determination on eligibility. As law permits, we may use and share the information you submit, including with other Federal, State, or local agencies, employers, and others as outlined in the routine uses within System of Records Notices (SORN) 60-0059 and 60-0089, available at www.ssa.gov/privacy. The information you submit may also be used in computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup debts under these programs.

Privacy Act Statement Template for Verbal Collections (SSA-820-BK Phone)

Privacy Act Statement
Collection and Use of Personal Information

Sections 223(d) and 1633 of the Social Security Act allow us to collect this information, which we will use to determine benefits eligibility.  Providing this information is voluntary, but not providing the information may prevent an accurate determination on your eligibility.  As law permits, we may disclose your information per routine uses in System of Records Notices 60-0059 and 60-0089, available at www.ssa.gov/privacy.  Your information may also be used in computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup debts under these programs.