Form SSA-7163 Questionnaire About employment or Self Employment Outsid

SOCIAL SECURITY ADMINISTRATION

Fonn APW".~
OMS IM. 08600060

TOE 2 2 0

QUESTIONNAIRE ABOUT EMPLOYMENT OR SELF-EMPLOYMENT OUTSIDE THE UNITED STATES
(See Reverse for Privacy Act Notice)
PLEASE PRINT YOUR ANSWERS
NAME OF WORKER ON WHOSE ACCOUNT BENEFITS ARE BEING PAID

WORKER'S SOCIAL SECURITY CLAIM NUMBER

NAME OF EMPLOYED OR SELF-EMROYED BENEFICIARY

BENEFICIARY'S SOCIAL SECURITY NUMBER 111 different lrom

--- I-- I ---WOTWSI

--- I-- 1---1. Give the following information about your employment or self-employment outside the United States.
Work Period
NAME AND ADORESS OF EMPLOYER ,IF SEE-EMFiOYED. SHOW
'SELF-AND ADWESS OF Y O U R T M D E OR BUSINESS.)

N P E OF BUNNESS

DATE EGAN
W .Y.4

Ih*.

DATE ENDW I h n f h . Day. Year) IIF
NOT ENDED. PRINT -NOT ENDED'.]

2. List any month(s1 of the work periodls) shown in item 1 in which you worked 46 hours or less and explain fully:
EXRANATION OF W Y YOU WE= EtStOVED OR SELF-EMPLOYED 46 HOURS OR LESS IN M O M H I S I LISTED. Ill your
.mpY_nnt -nmt
ull. lm w r k of 46 hous or -1
month, nnloh I oapy of the g ~ m e n or
f
u6n.n s u t m m n t tmm
W Y ' rn+w.,
uG4.ning th. trm*.
,
In* . p r r m m l

MONTH

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 t o item 4.)
Yes
[7 NO
(If "Yes," enter the total amount of wages earned during each year of the work period.)
TOTAL WAGES (AS SHOWN ON U.S. FDAMW-2 EFORE PAYROLL DEDUCTIONS)

YEAR

$

$

(b) If you are now employed, please submit an estimate of the gross wages (before payroll deductions) you expect
t o earn this year. S
IF YOU WERE SELF-EMPLOYED DURING THE WORK PERIOD SHOWN IN ITEM 1, ANSWER QUESTION 4.
If not, skip to item 7.
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 41b). If "No", go on to item 7.)
Yes
No
Ib) If you had the option t o elect Social Security coverage under a program other than the United States Social
yes
NO
Security program, did you elect such coverage7
(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)
5. Did you file income tax returns with the United States Internal Revenue Service for all years shown in item I ?
n ~ e s NO
(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.)
Form SSA-7163 (8-2001) Destroy Prior Editions EF (9-2001) 111 you need more space use the REMARKS section on the reverse.)

If you answer "No" t o 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 filing in REMARKS.
GROSS EARNINGS

YEAR

NET

BUSINESS EXPENSES

$

$

$

$

$

$

EARNINGS

6. If you are now self-employed, show how much you expect your net earnings to be for the current year.
$
REMARKS: (This space may be used for explaining any snswen to the questiom. If yw need

more space, arrsoh a separste sheer.)

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.

DATE SIGNED

SIGNATURE (FIRST NAME. MIDDLE INITIAL. LAST NAME1 (WRITE IN INK)

IMONTH. DAY. YEAR)

I
TELEPHONE NUMBERIS1AT WHiCH YOU M A Y BE
CONTACTED DURN
l G THE DAY llmiud. Area Code)

MAILING ADDRESS (NUMBER & STREET. APT NO. P 0 BOX. O
R RURAL ROUTE)

I
CITY

ENTER NAME OF COUNTRY IN WlCH YOU NOW LIVE.

POSTAL CODE

-

Witnesses are required ONLY if this statement has been sianed bv mark (. X.I above. If sianed bv mark (XI,
. .. two witnesses t o the
signing who know the claimant must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
I
ADDRESS

(No. and sneer,

ciry, counrry and postal codel

ADDRESS

(No. and street, city, counrty and posral codel

PRIVACY ACTIPAPEIWORK ACT NOTICE
S T I I T d l C R * AJTnOR TY Tn s lolm ~.g..sIs
nlolnul on .n*r
ih. aulho#,n ot Smcton 205 o l ih. Social 5.cb< I?Act
MllhO~TORIOR .O-JhTARb I I manrutoc. that ,o. I.#".*m. n1o,m.,on
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exowdad me annu.1 .amn
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iimitstim l e t by i.w.
EFFECT: F.iIure lo sanpleta this form wnhin a reasonabls time wlll oanstiture justitlation fa. dclarminatim that your bsntmlr ars wbi.sl lo Muctions for such months ss may bs spcified by
th. soe.i1 security A&"iantbn.
PURPOSE: The informtion is nehd to *ermine whaher won; dsdurtiao mr. applicabi. u n d r S o t i o n 203 01 the W.i1 %evriN As*.
OTHER ROLlTiNE USES: a h e r " I 1 which m.y b. ma6 of tha mtormaUon are: Ili t o Fadlitat. rtltiSUai rcrursh and sudl? ~srlviti.8 W S - r y to aswra Ih. inT.pmy and imprOv.man? ot th.
W e i %suri?v Provsma; and 121 lo comply with Fd
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taws requsing tM exclunw of infamalim bnwmrn SSA and another a w 0 Y .

eve

by somput.r.M
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the inforw~bn
US WIW"
r g n s * s may use "mshing pr0r.m.
I. tin* a prove ,ha, a parson qu1
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2.

Resident

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pud by th. F.dn.1

our r r o r d with tho- of o
m., ~ s d s r t ~SI.~.. or 1m.1 govemmsnt age mi.^.
w
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ilbwo .u 10 do 'hC a"." if you 0 no, .wee 10 It.

pvnnme",.

any

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- You are a resident of a country if you make your temporary or permanent home there, IVisiting as a tourist. or on a short business trip.

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

does not establish residence in

consider to be your permanent home.)

Thefollowing revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 5 3507, as amended by section 2 of the Pa~envorkReduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 12
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time esfimaie above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send on[v comments relating to our time estimate to this
address, not the completed form.