HTML Preview Employee Work Report page number 1.
Form SSA-821-BK (04-2012) ef (04-2012)
Social Security Administration
Retirement, Survivors, and Disability Insurance
Important Information
FO Address:
Date:
Claim Number:
We are writing to you because we need to know more about your work. Please tell us about your
work since
. We will use this information to decide if you can receive or continue
to receive disability benefits.
What You Need To Do
Please complete and return the completed form within 15 days to the address shown above. It is
important to fill out the form carefully and completely. Remember to sign and date the form. If you do
not return this form, we may contact your employer or make our determination based on the evidence
we have in our records.
Some Information To Help You Complete This Form
Our records show these employers and yearly earnings for you. This list may not be complete. It may
not show your work for this year or last year. You should add any additional work information as you
complete the form.
Employer Name Year Earnings