Form SSA-7163A-F4 Supplemental Statement Regarding Farming Activities of P

. SOCIAL

Form Approved

SECURITY ADMlNlSTRATlON

TOE 220
SUPPLEMENTAL STATEMENT REGARDING FARMING ACTIVITIES
OF PERSON LIVING OUTSIDE THE U.S.A.
(This statement is to be completed by a beneficiary living on a farm or operating a
farm outside the United States.) (See Page 4 for Privacy Act/Papemtonk Act Notice.)

OMB NO. 0980-0103

SOCIAL SECURITY CLAIM NUMBER

NAME OF BENEFICIARY

l a . GIVE THE DATE YOUR FARM RESIDENCE

l c . HOW DID IT END? (Sale, lease of land, etc.)

l b . GIVE THE DATE IT ENDED

OR OPERATION BEGAN OUTSIDE THE U.S.

I

2a. DO YOU OWN THE FARM?

I

2b. GlVE NAME OF THE OWNER AND INDICATE HIS RELATIONSHIP TO YOU

2c. EXPLAIN THE TYPE OF AGREEMENT OR CONTRACT YOU HAVE WlTH THE OWNER

2d. HOW ARE YOU PAID? /Check one1
DAILY

WEEKLY

MONTHLY

OTHER (specify)

3. WHAT PHYSICAL OR MANAGEMENT SERVICES DO YOU PERFORM IN CONNECTION WlTH THE FARM?

4a. WHAT IS THE LAND AREA OF THE
FARM?

4b. HOW MUCH OF THIS LAND IS USED FOR
( 1 ) GROWING CROPS

(2) GRAZING ANIMALS

(3) ORCHARDS (Olive, fig, or
other food-bearing trees or
vines/

(4) OTHER
(Explain1

Answer Questions 5 through 12 if you own or operate the farm. Be sure to sign this statement.

5. Give below the types and quantity of livestock, poultry, crops, and produce RAISED on the farm in the present year
and last vear.
PRESENT YEAR

a.

TYPES OF LIVESTOCK AND POULTRY

b.

TYPES OF CROPS

LAND AREA USED

LAST YEAR
NO. OF HEAD

YIELD

TYPES OF LIVESTOCK AND POULTRY

TYPES OF CROPS

LAND AREA USED

NO. OF HEAD

YIELD

6. Give below the following information about the livestock, poultry, crops, and produce SOLD.
PRESENT YEAR
ITEMS

QUANTITY

LAST YEAR
AMT. RECEIVED
/local currency1

Form SSA-7163A-F4 (8-2001) Destroy Prior Editions EF (9-2001)

ITEMS

QUANTITY

AMT. RECEIVED
(local currency)

PAGE 1

(over)

7. Give below the following information about livestock, poultry, crops or produce which the family used or
bartered.

ITEM

I
I

I

PRESENT YEAR

AMT. USED
ONFARM

I ."" I
I

AMT. AND KIND OF GOODS
AND/OR SERVICES
RECEIVED I N EXCHANGE FOR
BARTERED GOODS

I

1 I
ITEM

1

I

AMT. USED
ONFARM

1

LAST YEAR
AMOUNT
BARTERED

1

I

AMT. AND KIND OF GOODS
AND/OR SERVICES
RECEIVED IN EXCHANGE FOR
BARTERED GOODS

I

8. Give below the following information about other income or payments received from your farming operation (such as
government agricultural program payments, patronage dividends, breeding fees, etc.)
PRESENT YEAR
TYPE OF INCOME

LAST YEAR
AMOUNT RECEIVED
llocal currency)

TYPE OF INCOME

AMOUNT RECEIVED
(local currency)

9. Give description and age of farm equipment or machinery you have (such as tractor, wagon, truck, etc.) (If none,
show none.)

10.What animals do you have to work the farm? (If none, show none.)

Form

SSA-7163A-F4 (8-2001 EF (9-2001

PAGE 2

Il a .

Give the name and relationship to you (if any) of each person workinn on the farm.
NAME

D,

RELATIONSHIP

DESCRIBE DUTIES PERFORMED

nuw nne ~ n t rnlur
r
r~necxeppmpnareooxorwxes~

CROP OR
LIVESTOCK SHARE

CASH WAGE

ROOM AND
BOARD

12.List expenses (in local currency) for the present year and last year.
/Do not include material supplied by Government agencies.)
YEAR

TYPE OF EXPENSE

COST

TYPE OF EXPENSE

COST

1. Present
2. Last

Labor hired

1.
2.

Electricity, gasoline and
other fuel

1.
2.

1. Present
2. Last

Feed, seeds and
fertilizer purchased

1.
2.

Livestock and poultry
purchased

2.

1. Present
2. Last

Veterinary fees

1.
2.

Taxes and interest on
farm notes

2.

1. Present
2. Last

Machine hire

1.
2.

Other expenses
(Specify belo wl

1.
2.

1. Present
2. Last

Farm supplies and cost
of repairs

1.
2.

I.

I.

1.
2.

REMARKS: (This space may be used for any additional inforination you may wish to give1

.

Knowing that anyone making a false statement or representation of a material fact in application or for use in determining
a right t o payment under the Social Security Act commits a crime punishable under Federal law, Icertify that the above
statements are true.
If this statement has been signed by mark (x), or fingerprint, two
witnesses who know the signer must sign below, giving their full
addresses.
1. SIGNATURE OF WITNESS

ADDRESS OF WITNESS (Street number, city and country)

2. SIGNATURE OF WITNESS
ADDRESS OF WITNESS (Street number, city and country)

Form SSA-7163A-F4 (8-2001 EF (9-2001)

SIGNATURE OF PERSON COMPLETING THIS STATEMENT
(first name, middle initial, last name) (Write in ink)

HERE

STREET ADDRESS

CITY, COUNTRY, POSTAL CODE
DATE (Month, day and year)

PAGE 3

PRIVACY ACTIPAPERWORK ACT NOTICE

The information requested on this form is sought pursuant to the authority granted in 42
U.S.C. 403(b), 403(c), and 405(a). The information provided will be used t o confirm past and
continuing entitlement to benefits and to determine whether such benefits are subject to
deductions. Other uses which may be made of the information are summarized below. Failure
t o provide all or any part of the requested information is cause for suspension of benefit
payments. It is required that an individual under full retirement age receiving retirement
insurance benefits report any noncovered work which he or she engaged in outside the United
States. The failure to report these events may result in penalty deductions being made from
benefit payments. This notice is given pursuant to section 3 of the Privacy Act of 1974. If you
need help in completing this form, the people at any U.S. Embassy or consular post will be
glad to help you.

OTHER USES WHICH MAY BE MADE OF THE INFORMATION
The information you furnish on this form 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; and
3. To comply with Federal laws requiring the exchange of information between SSA
and another agency.

// //

PAPERWORK REDUCTI
ACT STATEMEN The Paperwork Re ction Act of 1995 requires
53507,
to notify
as ame
you tha
ed byis Section
information
2 cothection
Paperwork
meets the
R clectionnce
Act
requirement
of 1
44are
U.S.C.
not
us

required to
swer these que ' ns unless we dis y a valid Offic of Management and
take you abo 60 minutes to read the
Budget c
rol number. W estimate that it
instruc ' ns, gather the n essary facts, and a wer the questio

Form SSA-7163A-F4

(8-2001)

EF

(9-2001)

PAGE 4

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. 8 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 60
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 estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send & comments relating to our time estimate to this
address, not the completedform.