Employee Work Report

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Type of Payment Example Name and Address of Payer Amount ABC Company 123 Any Street Your Town, MD 54321 Date Worked (MM/YYYY-MM/YYYY) 100 per day, week, month, or year 01/2000 - 02/2000 Back Pay per Vacation Pay per Holiday Pay per Bonus or Commission per Royalties per Sick Pay per Disability Pay per Insurance Payment per Workers Comp per per Other (Please explain) Form SSA-821-BK (04-2012) ef (04-2012) Destroy Prior Editions Page 1 Claim : 3A.. Yes Special Condition Employer Name Date (MM/DD/YYYY) Reasons for Changes in Work Activity My physical and/or mental condition(s) Special conditions that allowed me to work were removed Stopped working Other reasons (please explain in 6B) My physical and/or mental condition(s) Special conditions that allowed me to work were removed Reduced my work hours Other reasons (please explain in 6B) My physical and/or mental condition(s) Special conditions that allowed me to work were removed Reduced my earnings Other reasons (please explain in 6B) My physical and/or mental condition(s) Changed to a lighter or easier type of work Special conditions that allowed me to work were removed Other reasons (please explain in 6B) No, I did not make any changes since the date shown in the Identification section.. Date Earned Date Earned Date Earned Amount Amount Amount MM/YYYY MM/YYYY MM/YYYY Form SSA-821-BK (04-2012) ef (04-2012) Page 9 Claim : ADDITIONAL EMPLOYMENT INFORMATION (Continuation from Page 3) Employer s Name Area Code and Telephone Number Area Code and Fax Number Mailing address City State ZIP Code Job Title and Type of Work Date Work Started (MM/DD/YYYY) Date Work Ended (if ended) (MM/DD/YYYY) Still working Rate of Pay per Hours Worked per Week (on average) Attach copies of all your pay stubs from this employer or ask the employer for a wage print-out showing gross monthly earnings since the DATE shown in the Identification section..

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