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Fillable Printable Form SSA-7163

Fillable Printable Form SSA-7163

Form SSA-7163

Form SSA-7163

Form SSA-7163 (03-2014) EF (03-2014)
Destroy Prior Editions
SOCIAL SECURITY ADMINISTRATION
QUESTIONNAIRE ABOUT EMPLOYMENT OR
SELF-EMPLOYMENT OUTSIDE THE UNITED STATES
(See Page 3 for Privacy Act Statement)
Form Approved
OMB No. 0960-0050
TOE 220
PLEASE PRINT YOUR ANSWERS
WORKER'S SOCIAL SECURITY CLAIM NUMBER
BENEFICIARY'S SOCIAL SECURITY NUMBER (If
different from worker's)
1. Give the following information about your employment or self-employment outside the United States.
NAME AND ADDRESS OF EMPLOYER (IF
SELF-EMPLOYED, SHOW "SELF"AND ADDRESS
OF YOUR TRADE OR BUSINESS.)
TYPE OF BUSINESS
Work Period
DATE BEGAN
(Month, Day, Year)
DATE ENDED (Month, Day, Year)
(IF NOT ENDED, PRINT "NOT
ENDED".)
2. List any month(s) of the work period(s) shown in item 1 in which you worked 45 hours or less and explain fully:
MONTH
EXPLANATION OF WHY YOU WERE EMPLOYED OR SELF-EMPLOYED 45 HOURS OR LESS IN MONTH(S)
LISTED. (If your employment agreement calls for work of 45 hours or less a month, attach a copy of the
agreement or a written statement from your employer explaining the terms of the agreement)
IF YOU WORKED AS AN EMPLOYEE FOR WAGES DURING A WORK PERIOD SHOWN IN ITEM 1, ANSWER
QUESTION 3. IF NOT, SKIP TO ITEM 4.
3. (a) Was the employment covered under the United States Social Security program; i.e., were the wages subject to
United States FICA taxes?
(If "No," go on to item 4.)
(If "Yes," enter the total amount of wages earned during each year of the work period.)
YesNo
YEARTOTAL WAGES (AS SHOWN ON U.S. FORM W-2 BEFORE PAYROLL DEDUCTIONS)
(b) If you are now employed, please submit an estimate of the gross wages (before payroll deductions) you expect to
earn this year.
IF YOU WERE SELF-EMPLOYED DURING THE WORK PERIOD SHOWN IN ITEM 1, ANSWER QUESTION 4. If not,
skip to item 7.
(If you need more space use the REMARKS section on Page 2.)
Page 1
NAME OF WORKER ON WHOSE ACCOUNT BENEFITS ARE BEING PAID
NAME OF EMPLOYED OR SELF-EMPLOYED BENEFICIARY
$
$
$
$
If you answer "No" to question 5, furnish a breakdown of your gross receipts, business expenses, and net earnings for
each year shown in item 1 and explain your reason for not filling in REMARKS.
YEARGROSS EARNINGSBUSINESS EXPENSESNET EARNINGS
6. If you are now self-employed, show how much you expect your net earnings to be for the current year.
ALWAYS COMPLETE THIS PORTION
I know that anyone who makes or causes to be made a false statement or representation of material fact in an application
or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law
by fine, imprisonment or both. I affirm that all information I have given in this document is true.
SIGNATURE OF BENEFICIARY
7. SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
MAILING ADDRESS (NUMBER & STREET, APT. NO., P.O. BOX, OR RURAL
ROUTE)
CITYENTER NAME OF COUNTRY IN WHICH YOU NOW LIVE.
DATE SIGNED
Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the claimant must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
ADDRESS (No. and street, city, country and postal code)
2. SIGNATURE OF WITNESS
ADDRESS (No. and street, city, country and postal code)
Form SSA-7163 (03-2014) EF (03-2014)
5. Did you file income tax returns with the United States Internal Revenue Service for all years
shown in item 1?
(If "Yes", attach a copy of Schedule C (or F) and SE and Form 2555 of your United States Income Tax Return filed for
each year of the work period shown in item 1. If your earnings derived from a partnership, attach a copy of Form 1065.)
NoYes
(b) If you had the option to elect Social Security coverage under a program other than the
United States Social Security program, did you elect such coverage?
(If "No," answer items 5 and 6. If "Yes," list the country under whose program you elected
coverage and go on to item 7.)
(country)
NoYes
Page 2
4. (a) While self-employed outside the United States, were you either a legal resident of the
United States or a United States citizen? (If "Yes", answer item 4(b). If "No", go on to item 7.)
NoYes
$
$
$$
$
$
$
$
$
$
REMARKS: (This space may be used for explaining any answers to the questions. If you need more space, attach a
separate sheet.)
(MONTH, DAY, YEAR)
TELEPHONE NUMBER(S) AT WHICH
YOU MAY BE CONTACTED DURING
THE DAY (Include Area Code)
POSTAL CODE
EXPLANATION OF TERMS USED IN THIS QUESTIONNAIRE
1. United States - Include the 50 States, District of Columbia, Puerto Rico, the U.S. Virgin Islands,
Guam, and American Samoa.
2. Resident - You are a resident of a country if you make your temporary or permanent home there.
(Visiting as a tourist, or on a short business trip, does not establish residence in a country. But going
into a country, setting up permanent quarters there for yourself and your family, and settling down in
the community generally make you a resident of that country even though you intend to return
eventually to another country which you consider to be your permanent home.)
This information collection meets the clearance requirements of
44 U.S.C. ยง3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take you about 12 minutes to read the instructions, gather the
necessary facts and answer the questions.
Collection and Use of Personal Information
Sections 203 and 205 of the Social Security Act, as amended, authorize us to collect this information.
We will use the information you provide to determine applicable work deductions.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making an accurate and timely decision on your benefits.
We rarely use the information you supply us for any purpose other than to determine continued
eligibility of Social Security benefits. However, we may use the information for the administration of
our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to private
entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notices 60-0059, entitled, Earnings Recording and
Self-Employment Income System and 60-0089, entitled, Claims Folders Systems. Additional
information about these and other system of records notices and our programs are available online at
www.socialsecurity.gov
or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person's eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
PRIVACY ACT STATEMENT
PAPERWORK REDUCTION ACT:
Form SSA-7163 (03-2014) EF (03-2014)
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