TN 9 (11-15)
DI 10510.025 Documenting Self-Employment Cases Using the SSA-820-BK (Work Activity Report-Self-Employment) and the SSA-823 (Report of SGA Determination- For SSA Use Only)
A. Purpose of the SSA-820-BK
The field office (FO) and processing center (PC) use the SSA-820-BK (Work Activity Report Self-Employment) to document work activity and to determine if any work incentives apply prior to making a substantial gainful activity (SGA) determination for initial claims, appeals, and continuing disability review (CDR) cases. To document the SGA decision, use the SSA-823 (Report of SGA Determination – For SSA Use Only).
B. When to complete the SSA-820-BK
Complete the SSA-820-BK to evaluate self-employment and work incentives for work CDR cases and initial applications with self- employment:
after the alleged onset date;
after the potential onset date (POD) when the POD is earlier than the AOD;
after the date the claimant alleges his or her impairment(s) first began to interfere with his or her ability to work;
after the controlling date in disabled widow(er)'s benefit (DWB) claims;
any time in childhood disability benefit (CDB) claims;
after the filing date in supplemental security income (SSI) claims (for statutory blindness cases, see DI 11005.072B.2); and
after age 55 in certain blindness claims (see DI 13010.135).
If there are multiple instances of self-employment that differ substantially from period to period, use separate forms, when necessary. Use the SSA-821-BK (Work Activity Report - Employee) in work and employee cases (for more information on the SSA-821-BK, see DI 10505.035).
C. How to access and store the SSA-820-BK
1. Initial claims for certified electronic folder (CEF) cases
Access the SSA-820-BK through Electronic Disability Collect System (EDCS). Use the following instructions to process CEF cases:
complete the SSA-820-BK per DI 10505.035D;
store the SSA-820-BK in eView; and
check eView for legibility.
2. Initial claims for CEF exclusion and limitation cases
Any claim excluded from electronic processing results in a paper folder. If you are creating an SSA-820-BK for a CEF exclusion or limitation case:
access the SSA-820-BK through UniForms;
fax the SSA-820-BK into the Non-Disability Repository for Evidentiary Document (NDRED); and
insert it into the blue section of the Modular Disability Folder (MDF).
NOTE: It is extremely important that the SSA-821-BK and any related documents are available to the DDS. Before transferring any case to the DDS, the FO must always check the certified claims file record management system (CFRMS) for any SSA-820-BK and related documents not stored in the paper folder. If there are CFRMS forms that are not in the MDF, print and place them in the MDF prior to forwarding to the DDS.
3. Work CDR cases
Prepare the SSA-820-BK in eWork for all work CDR cases.
use the attestation script outlined in Alternative Signature Methods - GN 00201.015F;
complete the SSA-820-BK per DI 10505.025D;
enter “ATTEST” along with the office code and name of the interviewer beneath the penalty clause in the block provided for “Signature of claimant, Beneficiary or Representative;”
document the eWork development worksheet with an “ATTEST” issue and enter the receipt date;
scan the SSA-820-BK into eView or NDRED; and
give or mail the claimant a DPS generated attestation cover notice and a copy of the SSA-820-BK
NOTE: Work CDR attestation applies only when development is done using the eWork development worksheet.
For wet signatures:
NOTE: If the FO receives an SSA-820-BK for a work CDR under PC jurisdiction, fax the SSA-820-BK into paperless by using the PC paperless barcode. For more information on routing work CDR documentation, refer to DI 13010.026B.
D. How to complete the SSA-820-BK
1. Cover notice
The cover notice must remain attached to the SSA-820-BK. The notice provides the public with information about:
why we are requesting work information;
when we expect the claimant to return the form; and
the employment information we have in our records
In addition, the cover notice provides referral information and advises the claimant or beneficiary to read the mandatory enclosed pamphlet, “Working While Disabled-How We Can Help.” Be sure to include this publication when you mail or give the SSA-820-BK to the claimant or beneficiary
2. Section: Identification-To Be Completed by SSA
Complete as follows:
enter name(s) and SSN(s) in the appropriate boxes;
check appropriate “Blind” or “Not Blind” box;
show claim number and beneficiary identification code (BIC); and
insert appropriate work development date (i.e., alleged onset date, date of onset, date of entitlement, or last determination date).
3. Section: Information to Be Answered By Person Applying For or Receiving Benefits
Check whether there was self-employment income, but no self-employment work activity, since the date in the identification section. If “no” is checked, question 2 must be answered, otherwise, skip to question 3.
This question captures information about income that does not represent self-employment work activity. Complete what the payment was for, the name and address of the payer, the amount, or estimate of the payment. Skip to question 9.
Complete self-employment business information, and check the type of ownership arrangement. If the claimant or beneficiary has a farm arrangement, see instructions in this section, DI 10510.025F.
This question captures information about net earnings and hours worked. If a self-employed individual is working more than 45 hours per month, we may determine a finding of SGA. Show each month, the net earnings, and check if the claimant or beneficiary worked more than 45 hours a month. Evaluate this section by referring to DI 10510.015, Test One of the General Evaluation Criteria-Significant Services and Substantial Income.
NOTE: If you are making a trial work period (TWP) determination, 80 hours constitutes a TWP service month (see DI 13010.060).
The claimant or beneficiary may choose to attach his or her tax return, rather than completing the chart. If income tax returns are not attached, follow instructions in this section, DI 10510.025E.
Show the extent that the claimant or beneficiary executed management responsibilities. For more information on significant services, see DI 10510.015B.
Identify the effect that the disability has on the claimant or beneficiary’s ability to perform his or her duties, and what additional assistance is required because of the disability. Be aware of UWAs. For more information on UWAs, see DI 11010.145.
Identify possible unpaid help or un-incurred business expenses deductions. We can deduct the value of donated business items, such as rent-free space, heat, utilities, or services from gross earnings in determining countable income. For more information on unpaid help and un-incurred business expenses, see DI 10510.012.
Collect information on impairment-related work expenses (IRWE). These items or services are required for the self-employed claimant or beneficiary to work. For more information on IRWE, see DI 10520.001.
4. Section: Remarks
Document any additional information that the claimant or beneficiary did not have space for in other parts of the form. Do not use this section to document your SGA rationale.
5. Section: Signature
Inform the claimant or beneficiary that by attesting this form they are authorizing any employer, agency or other organization to disclose information about their physical and/or mental condition or their work to SSA, or the State Agency that may determine their entitlement to disability benefits.
Signature proxy applies to the SSA-820-BK when you take an initial claim or when completing a work CDR using eWork development worksheet. For more information on alternative signature requirements, see GN 00201.015 or DI 81010.120.
If a third party refuses to sign, document the form with “Refused to sign.” Also note the source of the information, and if possible, the reason for the refusal.
E. Documenting allegations and obtaining corroborative evidence
It is essential that the evidence includes not only what the claimant’s or beneficiary’s activities have been since the alleged onset date of disability (or since the last work review for subsequent work CDR), but also how the activities compare with those he or she performed before that date.
Document an alleged decline in the claimant’s or beneficiary’s activities after the alleged onset date, and how this decline affected the business. Make every attempt to obtain a clear explanation regarding how he or she modified services after the alleged date of onset.
Obtain corroborative evidence whenever there is any indication that the claimant or beneficiary may not be giving a full and accurate statement about the business. Corroborative evidence should include income tax returns, statements by customers, employees, sales clerks, suppliers, and others having dealings with the business, as well as your own direct observation of business activities and conditions.
F. Coordination of coverage and SGA development in farm cases
The information given on the SSA-7156 (Farm Self-Employment Questionnaire) and SSA-7157-F4 (Farm Arrangement Questionnaire), obtained in the development of earnings and coverage, is pertinent to an SGA determination. This form also collects a thorough explanation on the experience, education, and training of the claimant or beneficiary. For more information on the SSA-7156, see RS 01804.200.
G. Controlling the return of the SSA-820-BK
Follow the same instructions as you would for the SSA-821-BK, in DI 10505.035 to control for the return of SSA-820-BK.
H. When to complete the SSA-823 (Report of SGA Determination-For SSA Use Only)
You must complete the SSA-823 in all initial claim determinations that require an SSA-820-BK or SSA-821-BK. You must complete the forms prior to sending the case to DDS. In post-entitlement (PE) situations, you may complete the form to document your rationale in self-employment cases that require you to use the three tests under the general evaluation criteria or to document your rationale for unusual circumstances. For PE cases, you may also complete the form to document subsidy, IRWE, or UWA issues. If eWork sufficiently documents all issues, you are not required to complete the SSA-823. If you cannot use eWork to process your decision, you must complete the SSA-823.
NOTE: For initial claims with an allegation of statutory blindness, see DI 11010.170.
I. Related references
DI 10505.000 Evaluation and Development of Employment - Table of Contents
GN 00201.015 Alternative Signature Methods
DI 10510.010 SGA Criteria in Self-Employment
DI 13010.025 FO Responsibilities in Work Issue CDRs
DI 81010.030 Certified Electronic Folder (CEF) Exclusions and Limitations
DI 81010.090 Faxing Documents into the Certified Electronic Folder (CEF) Using Barcodes
DI 81010.120 Using Form Attestation for Work Activity Reports
DI 81010.140 Processing Field Office (FO) Determinations
GN 00201.015 Alternative Signature Methods
OS 15025.010 SSA-821-BK Work Activity Report-Employee