Access the SSA-820-BK through Electronic Disability Collect System (EDCS). Use the following instructions to process CEF cases:

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  complete the SSA-820-BK per DI 10510.025D;

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  store the SSA-820-BK in eView; and

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  check eView for legibility.

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:

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  access the SSA-820-BK through UniForms;

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  fax the SSA-820-BK into the Non-Disability Repository for Evidentiary Document (NDRED); and

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  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.

Prepare the SSA-820-BK in eWork for all work CDR cases.

1. 1. 

   For attestation:

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     use the attestation script outlined in Alternative Signature Methods - GN 00201.015F;

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     complete the SSA-820-BK per DI 10505.025D;

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     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 payee;”

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     document the eWork development worksheet with an “ATTEST” issue and enter the receipt date;

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     Fax the SSA-820-BK into eView. If there is no eView, fax into NDRed; and

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     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.

2. 2. 

   For wet signatures:

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     scan the form into eView or NDRED; and

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     receipt in the eWork issue.

   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.

The cover notice must remain attached to the SSA-820-BK. The notice provides the public with information about:

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  why we are requesting work information;

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  when we expect the claimant to return the form; and

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  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

Complete as follows:

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  enter name(s) and BNC(s) in the appropriate boxes;

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  check appropriate “Blind” or “Not Blind” box; and

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  insert appropriate work development date (i.e., alleged onset date, date of onset, date of entitlement, or last determination date).

Question 1

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.

Question 2

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.

Question 3

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.

Question 4

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).

Question 5

The claimant or beneficiary may choose to attach their tax return, rather than completing the chart. If income tax returns are not attached, follow instructions in this section, DI 10510.025E.

Question 6

Show the extent that the claimant or beneficiary executed management responsibilities. For more information on significant services, see DI 10510.015B.

Question 7

Identify the effect that the disability has on the claimant or beneficiary’s ability to perform their duties, and what additional assistance is required because of the disability. Be aware of UWAs. For more information on UWAs, see DI 11010.145.

Question 8

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.

Question 9

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.

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.

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  Inform the claimant, beneficiary or representative payee 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.

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  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.

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  If a 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.