SSA WORK ACTIVITY REPORT GUIDE
Companion to Form SSA-821-BK
SECTION 1: BENEFICIARY INFORMATION
Full Legal Name: [________________________________]
Social Security Number: [___-__-____]
Date of Birth: [__/__/____]
Current Address:
Street: [________________________________]
City: [________________] State: [____] Zip: [________]
Telephone: [(___)___-____]
Email: [________________________________]
Type of Benefits Received:
☐ Social Security Disability Insurance (SSDI - Title II)
☐ Supplemental Security Income (SSI - Title XVI)
☐ Both SSDI and SSI (Concurrent)
☐ Childhood Disability Benefits (CDB)
☐ Disabled Widow(er)'s Benefits (DWB)
SECTION 2: EMPLOYMENT INFORMATION
A. Current/Recent Employer
Employer Name: [________________________________]
Employer Address:
Street: [________________________________]
City: [________________] State: [____] Zip: [________]
Employer Phone: [(___)___-____]
Supervisor Name: [________________________________]
Type of Business: [________________________________]
B. Employment Dates
Start Date: [__/__/____]
End Date (if applicable): [__/__/____] ☐ Still Employed
Reason for Leaving (if applicable):
☐ Disability-related
☐ Laid off/terminated
☐ Resigned
☐ Business closed
☐ Other: [________________________________]
C. Job Information
Job Title: [________________________________]
Job Duties (describe in detail):
[________________________________]
[________________________________]
[________________________________]
[________________________________]
Physical Requirements:
☐ Sitting: [____] hours per day
☐ Standing: [____] hours per day
☐ Walking: [____] hours per day
☐ Lifting: Maximum [____] lbs.
☐ Other: [________________________________]
SECTION 3: EARNINGS AND HOURS
A. Work Schedule
Days Worked Per Week: [____] days
Hours Worked Per Day: [____] hours
Total Hours Per Week: [____] hours
Schedule Type:
☐ Regular/fixed schedule
☐ Variable/irregular schedule
☐ Part-time
☐ Full-time
☐ On-call/as needed
B. Earnings
Pay Rate: $[________] per ☐ hour ☐ day ☐ week ☐ month ☐ year
Pay Frequency:
☐ Weekly
☐ Bi-weekly
☐ Semi-monthly
☐ Monthly
Gross Monthly Earnings (before deductions): $[________]
Net Monthly Earnings (after deductions): $[________]
C. Monthly Earnings History
| Month/Year | Gross Earnings | Hours Worked | Notes |
|---|---|---|---|
| [__/____] | $[________] | [____] | [________________________________] |
| [__/____] | $[________] | [____] | [________________________________] |
| [__/____] | $[________] | [____] | [________________________________] |
| [__/____] | $[________] | [____] | [________________________________] |
| [__/____] | $[________] | [____] | [________________________________] |
| [__/____] | $[________] | [____] | [________________________________] |
SECTION 4: SUBSTANTIAL GAINFUL ACTIVITY (SGA) ANALYSIS
2025 SGA Thresholds
Non-Blind: $1,620/month gross earnings
Blind: $2,700/month gross earnings
A. SGA Determination Worksheet
Step 1: Gross Monthly Earnings: $[________]
Step 2: Subtract Impairment-Related Work Expenses (IRWEs):
(See Section 5)
Total IRWEs: -$[________]
Step 3: Subtract Subsidies/Special Conditions:
(Value of support from employer beyond regular pay)
Total Subsidies: -$[________]
Step 4: Countable Earnings: $[________]
Is Countable Earnings Above SGA?
☐ Yes - May affect benefits
☐ No - Below SGA threshold
SECTION 5: IMPAIRMENT-RELATED WORK EXPENSES (IRWEs)
Definition
IRWEs are out-of-pocket expenses for items or services you need because of your disability in order to work. These can be deducted from gross earnings for SGA purposes.
A. Qualifying IRWEs
Check all that apply and provide amounts:
☐ Transportation:
- Modified vehicle: $[________]/month
- Specialized transportation: $[________]/month
- Mileage to medical appointments related to work: $[________]/month
☐ Medical Devices/Equipment:
- Wheelchair/mobility device: $[________]/month
- Prosthetics: $[________]/month
- Hearing aids: $[________]/month
- Other: [________________]: $[________]/month
☐ Medications:
- Prescription medications needed to work: $[________]/month
- (List medications): [________________________________]
☐ Attendant Care Services:
- Personal care assistance at work: $[________]/month
- Job coaching services: $[________]/month
☐ Service Animals:
- Food, veterinary care, equipment: $[________]/month
☐ Work-Related Equipment:
- Specialized tools/equipment: $[________]/month
- Ergonomic equipment: $[________]/month
☐ Other IRWEs:
Total Monthly IRWEs: $[________]
B. IRWE Documentation Checklist
☐ Receipts for all claimed expenses
☐ Medical documentation showing need due to disability
☐ Proof expenses are paid out-of-pocket (not reimbursed)
☐ Evidence items/services are needed for work
SECTION 6: SUBSIDIES AND SPECIAL CONDITIONS
A. Employer Support
Does your employer provide any of the following?
☐ Extra Supervision: More supervision than other workers
Estimated value: $[________]/month
Describe: [________________________________]
☐ Lower Production Standards: Fewer tasks or lower quotas
Estimated value: $[________]/month
Describe: [________________________________]
☐ Extra Breaks: More rest periods than other workers
Estimated value: $[________]/month
Describe: [________________________________]
☐ Modified Job Duties: Easier tasks than job normally requires
Estimated value: $[________]/month
Describe: [________________________________]
☐ Flexible Schedule: Accommodations for medical appointments
Estimated value: $[________]/month
Describe: [________________________________]
☐ Job Coaching: Support from vocational services
Estimated value: $[________]/month
Describe: [________________________________]
Total Monthly Subsidy Value: $[________]
B. Self-Employment Considerations
☐ Family members provide unpaid help
☐ Business has special arrangements due to disability
☐ Income does not reflect actual productive capacity
SECTION 7: TRIAL WORK PERIOD (TWP)
Definition
The Trial Work Period allows SSDI beneficiaries to test their ability to work for at least 9 months without losing benefits.
2025 TWP Service Month Threshold
A service month counts if you earn over $1,160 gross (or work 80+ self-employment hours).
A. TWP Tracking
TWP Start Date: [__/__/____]
Service Months Used:
| Month | Year | Earnings | TWP Month? |
|---|---|---|---|
| [________] | [____] | $[________] | ☐ Yes ☐ No |
| [________] | [____] | $[________] | ☐ Yes ☐ No |
| [________] | [____] | $[________] | ☐ Yes ☐ No |
| [________] | [____] | $[________] | ☐ Yes ☐ No |
| [________] | [____] | $[________] | ☐ Yes ☐ No |
| [________] | [____] | $[________] | ☐ Yes ☐ No |
| [________] | [____] | $[________] | ☐ Yes ☐ No |
| [________] | [____] | $[________] | ☐ Yes ☐ No |
| [________] | [____] | $[________] | ☐ Yes ☐ No |
Total TWP Months Used: [____] of 9
SECTION 8: EXTENDED PERIOD OF ELIGIBILITY (EPE)
Definition
After completing TWP, you have 36 months during which you can receive benefits for any month your earnings fall below SGA.
EPE Start Date: [__/__/____]
EPE End Date: [__/__/____]
Monthly EPE Status
| Month/Year | Countable Earnings | Above SGA? | Benefits Payable? |
|---|---|---|---|
| [__/____] | $[________] | ☐ Yes ☐ No | ☐ Yes ☐ No |
| [__/____] | $[________] | ☐ Yes ☐ No | ☐ Yes ☐ No |
| [__/____] | $[________] | ☐ Yes ☐ No | ☐ Yes ☐ No |
SECTION 9: UNSUCCESSFUL WORK ATTEMPT (UWA)
A. UWA Criteria
Work may be considered an Unsuccessful Work Attempt if:
☐ Work lasted 6 months or less
☐ Work ended or reduced to below SGA due to disability
☐ Work ended or reduced due to removal of special conditions
B. UWA Documentation
Work Period: [__/__/____] to [__/__/____]
Reason Work Ended/Reduced:
☐ Impairment worsened
☐ Could not perform job duties due to disability
☐ Required too many absences due to disability
☐ Employer removed accommodations
☐ Other disability-related reason: [________________________________]
Supporting Documentation:
☐ Doctor's note about inability to continue working
☐ Employer statement about performance issues
☐ Medical records showing condition worsening
☐ Other: [________________________________]
SECTION 10: CERTIFICATION
I certify that the information provided in this Work Activity Report is true, complete, and accurate to the best of my knowledge. I understand that:
- I must report all work activity to SSA.
- Failure to report may result in overpayments that must be repaid.
- Knowingly providing false information may result in penalties.
- SSA may verify this information with my employer.
Signature: _________________________________
Printed Name: [________________________________]
Date: [__/__/____]
IMPORTANT REMINDERS
Report Work Promptly: Notify SSA within 10 days of starting or stopping work.
Keep Records: Maintain copies of all pay stubs, receipts for IRWEs, and medical documentation.
Ticket to Work: Consider enrolling in Ticket to Work for employment support services.
Contact Information:
- SSA National Toll-Free: 1-800-772-1213
- TTY: 1-800-325-0778
- Online: www.ssa.gov/myaccount
SOURCES AND REFERENCES
END OF SSA WORK ACTIVITY REPORT GUIDE
About This Template
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Last updated: February 2026