Form SSA-7161-OCR-SM Report to U.S. SSA by Person Receiving Benefits for a Ch

7161

FORM APPROVED
OMB NO. 0960-0049

SOCIAL SECURITY ADMINISTRATION

REPORT TO UNITED STATES SOCIAL SECURITY ADMINISTRATION
BY PERSON RECEIVING BENEFITS FOR A CHILD OR FOR AN ADULT UNABLE TO HANDLE FUNDS
IMPORTANT: FAILURE TO COMPLETE AND RETURN THIS FORM WITHIN 60 DAYS WILL RESULT IN A
SUSPENSION OF BENEFITS. SIGN AND RETURN THIS FORM IN THE ENCLOSED ENVELOPE.
SEE INSTRUCTIONS ENCLOSED.

1.

Print your address here only if it is different from the one shown below.

Telephone number at which you may be
contacted during the day.

2.

•

IF YOU ANSWER “YES” TO ANY OF THE QUESTIONS 3 THROUGH 8 BELOW, PLEASE TURN THIS FORM OVER
AND CONTINUE ON THE BACK. YOU MUST SIGN YOUR NAME IN ITEM 11 ON THE BACK OF THIS FORM
YES
NO
Has anyone for whom you receive benefits changed his/her citizenship or country
of residence in the past 15 months?
®

3.
4.

Has anyone for whom you receive benefits married, had a divorce
(or annulment) or died in the past 15 months?

®

Has the parent (natural, adoptive or stepparent) of any child for whom you
receive benefits died, married or had a divorce (or annulment) in the past 15
months? (It is not necessary that the parent have been receiving benefits.)

®

Did anyone for whom you receive benefits work for someone else or own a
business or farm in the past 15 months?

®

Did any person for whom you receive benefits live apart from you during
any of the past 15 months?

®

Did you give the Social Security checks or the full amount of the benefits to
another person (for example, the beneficiary’s custodian or the beneficiary
himself) during the past 15 months?

®

5.

6.
7.
8.

9.

Were all Social Security benefits received during the past 15 months used for the
beneficiary and/or held for the beneficiary?
If “No”, explain in “Remarks” on the back of this form what was done with the benefits.

10. A.

Show the manner in which any amounts not
used for the beneficiary are being held:
Bank
Account

Other

B.

YES

NO

®

Show the Title or Ownership of the Account:

If “Other”, explain in
“Remarks” on the
back of this form.

OTHER REPORTABLE EVENTS
In addition to the events listed on this form, you are
responsible for reporting any other event that may
affect benefit payments.
Form SSA-7161-OCR-SM (03-2004) Destroy Prior Editions

(For SSA Use Only)
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SSN
7161

Continued on the
®
Reverse

IF YOU HAVE ANSWERED “YES” TO ANY OF QUESTIONS 3 THROUGH 8 ON THE OTHER SIDE OF THIS FORM, YOU
MUST COMPLETE THE CORRESPONDING BLOCK(S) BELOW. IF YOU ANSWERED “NO” TO ALL OF THE QUESTIONS 3
THROUGH 8 ON THE OTHER SIDE OF THE FORM,YOU SHOULD GO TO ITEM 11, SIGN, DATE, AND RETURN THE FORM.

3.

If you answered “Yes” to question 3 on the other side, complete the information below.
(b) Country of new
citizenship

(a) Name of person

4.

(b) Check which event occurred
(c) Date event
occurred
Marriage
Annulment
Divorce
Death

If you answered “Yes” to question 5 on the other side, complete the information below.
(b) Check which event occurred
(c) Date event
occurred
Death
Marriage
Divorce
Annulment

(a) Name of parent

6.

If you answered “Yes” to question 6 on the other side, complete the information below.
(b) Check one
Employee

(a) Name of person

(d) If ended, enter date work stopped

Yes

No

SelfEmployed

(c) Date work
began

(e) List each month that he/she worked 45 hours or less (Explain in Remarks)

(f) Was this work done in the United States or
did he/she pay United States Social
Security taxes on earnings from this work?

7.

(e) Date residence
began

If you answered “Yes” to question 4 on the other side, complete the information below.
(a) Name of person

5.

(c) Date
(d) Current country
acquired
of residence

(g) If you answered “yes” to (f), enter his/her
total earnings for last year
® $
AND give your estimate of this
year’s earnings.
® $

If you answered “Yes” to question 7 on the other side, complete the information below.
(a) Name of beneficiary who did not live
with you

(b) Date beneficiary left

(c) Reason for leaving

(d) Date beneficiary
returned

(e) If you listed someone in (a) above who has not returned, enter the address where he/she can be reached.
(Include ZIP code)

8.

If you answered “Yes” to question 8 on the other side, show to whom the funds were given.

Remarks

IMPORTANT: I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone
who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else
to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

11.

Signature or mark of payee (Note: If this form is signed with a mark, a witness must sign below.)

12.

Signature of witness

Form SSA-7161-OCR-SM (03-2004)

Address (include ZIP code)

Date

Date