Form SSA-7162-OCR-SM Report to U.S. SSA

7162

FORM APPROVED
OMB NO. 0950-0049

SOCIAL SECURITY ADMINISTRATION

REPORT TO UNITED STATES SOCIAL SECURITY ADMINISTRATION
IMPORTANT: Failure to complete and return this form within 60 days will result in 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 BELOW, PLEASE TURN THIS FORM OVER AND
CONTINUE ON THE BACK. YOU MUST SIGN YOUR NAME IN ITEM 7 ON THE BACK OF THIS FORM.

3.

4.
5.

YES

NO

Has there been a change in your citizenship or your country of residence that you have
not yet reported to SSA?
!
Have you married or had a divorce or annulment since you last reported your marital
status to SSA?

!

Did you work for someone else or were you self-employed (i.e., did you own a
business or farm) since your last report of work to SSA?

!

Answer Question 6 only if you are the parent of a child under age 16 or disabled and you
receive Social Security benefits because you have this child in your care.

6.

Did you and the child live apart since you last reported the child’s living arrangements
to SSA?

!

OTHER REPORTABLE EVENTS

(For SSA Use Only)

In addition to the events listed on this form, you are
responsible for reporting any other event that may
affect benefit payments.

—

—
SSN

PAPERWORK ACT AND PRIVACY ACT NOTICE
The information requested on this form is sought pursuant to the
authority granted in 42 U.S.C. 403(c) 403(g), 405(a) and 405(j). Your
response to the questions on this form is required for you to continue
to receive benefits. Failure to report those events which can cause
suspension of benefits may cause the loss of additional benefits.
The information provided will be used to confirm past and continuing
entitlement to benefits and may be disclosed by SSA to another
governmental agency for the following purposes: (1) to assist SSA in
establishing the right of an individual to Social Security coverage and/or
benefits; (2) to facilitate statistical research and audit activities
necessary to assure the integrity and improvement of the Social
Security programs; (3) to comply with Federal laws requiring the
exchange of information between SSA and another agency; and (4) to
comply with Freedom of Information Act (5 U.S.C. 552).

Explanations about these and other reasons why information you
provide us may be used or given out are available in Social Security
Offices. If you want to learn more about this, contact any Social
Security office.
Paperwork Reduction Act Statement - This information collection
meets the requirements of 44 U.S.C. § 3507, as amended by
section 2 of the Paperwork Reduction 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 5 minutes to read the instructions, gather the
facts, and answer the questions. You may send comments on
our time estimate above to: SSA, 1338 Annex Building,
Baltimore, MD 21235-0001, U.S.A. Send only comments relating to
our time estimate to this address, not the completed form.

We may also use the information you give us when we match records
by computer. Matching programs compare our records with those of
other Federal, State, or local government agencies. Many agencies
may use matching programs to find or prove that a person qualifies for
benefits paid by the Federal government. The law allows us to do this
even if you do not agree to it.
Form SSA-7162-OCR-SM (09-2004) Destroy Prior Editions

7162

Continued on the
!
Reverse

IF YOU HAVE ANSWERED “YES”TO ANY OF THE QUESTIONS ON THE OTHER SIDE OF THIS FORM, YOU MUST
COMPLETE THE CORRESPONDING BLOCK(S) BELOW. IF YOU ANSWERED “NO”TO ALL THE QUESTIONS ON
THE OTHER SIDE OF THE FORM, YOU SHOULD GO TO ITEM 7, SIGN, DATE, AND RETURN THE FORM.

3.

4.

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

Date acquired (Month-Day-Year)

(b) Current country of residence

Date of change (Month-Day-Year)

If you answered “Yes” to question 4 on the reverse, complete the information below.
(a)

5.

Marriage

(b)

Divorce

(c)

Annulment

(d) Enter date event occurred

If you answered “Yes” to question 5 on the reverse, complete the information below.
(a) Check one
Employee

SelfEmployed

(b) Date work began
(Month-Day-Year)

(c) If ended, enter date work stopped
(Month-Day-Year)

(d) List each month that you worked 45 hours or less. (Explain in “Remarks”)
(e) Was this work done in the United States or did you pay United States
Social Security taxes on earnings from this work?
(f) If you answered “yes” to (e) above, enter your total earnings for:

6.

the year before last
and

!

$

last year
also give

!

$

your estimate of earnings for this year

!

$

!

Yes

No

If you answered “Yes” to question 6 on the reverse, complete the information below.
(a) Date child left

(b) Date child returned (c) Name of child

(d) Reason for absence
(e) If the child has not returned, print the address of the child here.

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.

7.

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

Date

8.

Signature of witness

Date

Form SSA-7162-OCR-SM (09-2004)

Address (include ZIP code)