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

INSTRUCTIONS FOR COMPLETION OF FORM SSA-7161-OCR-SM
WHAT YOU NEED TO DO
First please read the instructions below. This is important
because not all questions are self-explanatory. Then,
complete your report and return it to the Social Security
Administration, P.O. Box 7161, Wilkes-Barre,
Pennsylvania, 18767-7161, U.S.A. in the enclosed envelope within 60 days from the day you receive it. If you do
not return it promptly, we may stop sending payments to you.
GENERAL INSTRUCTIONS
To help us process your report and avoid having to recontact you, please follow these instructions.
• Use black ink or a dark pencil to complete the report.
• Please print your answers, except in the signature
block.
• Place “X’s” in the appropriate “Yes” or “No” boxes on
the first page.
• On the first page, keep your “X’s” inside the boxes.
• You must sign the form on the back page.
HOW TO FILL OUT THE FORM
The numbers below match the numbered questions on
the report.
Item 1. Do not write in this space if the preprinted
address in the box is correct. If the preprinted address is
incorrect and you have not reported your new address to
the Social Security Administration, then print the correct
address in this space.
Item 2. Enter the telephone number at which you may be
contacted during the day in this space.
Item 3. Has anyone for whom you receive benefits
changed his/her citizenship or country of residence in the
past 15 months? If not, place an “X” in the “NO” box and
go on to item 4. If yes, place an “X” in the “YES” box and
turn the form over. In item 3 on the back, enter in:
(a) the name of the person;
(b) the country of new citizenship;
(c) the date the new citizenship was acquired; and/or
(d) the current country of residence;
(e) the date residence began.
Item 4. Has anyone for whom you receive benefits married, had a divorce (or annulment) or died in the past 15
months? If not, place an “X” in the “NO” box and go on to
item 5. If yes, place an “X” in the “YES” box and turn the
form over. In item 4 on the back, enter in:
(a) the name of the person;
(b) a check mark next to which event occurred;
(c) the date the event occurred.
Item 5. 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?
Form SSA-7161-INST(03-2004) Destroy Prior Editions

(Note that it is not necessary that the parent have been
receiving benefits.) If not, place an “X” in the “NO” box
and go on to item 6. If yes, place an “X” in the “YES” box
and turn the form over. In item 5 on the back, enter in:
(a) the name of the parent;
(b) a check mark next to which event occurred;
(c) the date the event occurred.
Item 6. Did anyone for whom you receive benefits work
for someone else or own a business or farm in the past 15
months? If not, place an “X” in the “NO” box and go on to
Item 7. If yes, place an “X” in the “YES” box and turn the
form over. In item 6 on the back, enter in:
(a) the name of the person who worked or owned a
business or farm;
(b) a check mark in the first block if he/she worked for
someone else or a check mark in the second block
if he/she was self-employed;
(c) the month, day, and year the work began;
(d) if the work has ended, enter the month, day, and
year the work ended. If not ended, write “Not
ended”;
(e) list each month in the work period indicated in (c)
and (d) above that he/she worked 45 hours or less.
(Explain in “Remarks” why his/her employment/selfemployment calls for 45 hours or less);
(f) if the work was done in the U.S. or if U.S. Social
Security taxes (FICA) were paid on earnings from
this work, check the “Yes” block. If not, check the
“No” block;
(g) if the answer in (f) above was “Yes” enter his/her
total earnings for the last year in the first space and
give an estimate of this year’s earnings in the next
space.
Item 7. Did any person for whom you receive benefits live
apart from you during any of the past 15 months? If not,
place an “X” in the “NO” box and go on to item 8. If yes,
place an “X” in the “YES” box and turn the form over. In
item 7 on the back enter in:
(a) the name of the person who did not live with you;
(b) the date he/she left;
(c) the reason for leaving;
(d) the date he/she returned. If he/she has not
returned, enter “Not returned”;
(e) the address where he/she can be reached.
Item 8. 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? If not, place an “X” in the “NO” box
and go on to item 9. If yes, place an “X” in the “YES” box
and turn the form over. In item 8 on the back, show to
whom the funds were given (the custodian, the beneficiary, etc.).

Item 9. Were all of the Social Security benefits received
during the past 15 months used for the beneficiary and/or
held for the beneficiary? If all the benefits were used or, if
all were not used, but the remainder were held for the
beneficiary, place an “X” in the “YES” box and go on to
item 10. If not, place an “X” in the “NO” box, turn the form
over and explain in “Remarks” what was done with the
benefits.

THE PRIVACY AND PAPERWORK REDUCTION ACTS

Item 10. A. Show the manner in which any amounts not
used for the beneficiary are being held. If the benefits are
not in a bank account, check “Other” and explain in
“Remarks” on the back. B. Show the title or ownership of
the account in which the amounts are held.

The information provided will be used to confirm past and
continuing entitlement to benefits and may be disclosed
by SSA to another person or 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).

BE SURE TO TURN THE FORM OVER AND ENTER
YOUR SIGNATURE (OR MARK) AND THE DATE IN
ITEM 11. IF YOU SIGN WITH A MARK, A WITNESS
MUST COMPLETE ITEM 12. IF A WITNESS SIGNS
THE FORM, HE/SHE SHOULD ENTER HIS/HER NAME,
ADDRESS, AND THE DATE IN ITEM 12.
ALL KINDS OF WORK SHOULD BE REPORTED
Every kind of work, trade, apprenticeship or business in
which the beneficiary engages while the beneficiary is
under age 66 MUST BE REPORTED. After you notify us
of work, we will inform you if the work has any effect on
benefits.
YOUR RESPONSIBILITY AS A REPRESENTATIVE
PAYEE
Your job is to use the Social Security benefits you receive
for the personal care and well-being of the beneficiary.
This is true whether you are relative, friend, court-appointed guardian, or official of a private agency or institution.
You must keep yourself informed of the beneficiary’s
needs, so you can decide how the benefits should be
used. You must account for the use of the benefits on
the form enclosed. This accounting will be reviewed by
the Social Security Administration and is subject to verification. Therefore, you should keep a record of the
amount of benefits you received and how you used them
(keep receipts, cancelled checks, etc.).
You must notify the Social Security Administration when
the beneficiary changes residence or you are no longer
responsible for the care and welfare of the beneficiary.
You must also report to us promptly if the beneficiary dies,
marries, is adopted, goes to work, or enters or leaves a
hospital or institution.

Form SSA-7161-INST(03-2004) Destroy Prior Editions

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.

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.
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.
See Revised PRA, Attached

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 15 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.

The following 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. § 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 15
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 only comments relating to our time estimate to this
address, not the completed form.

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)
—

—

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