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

. SOCIAL SECURITY ADMINISTRATION

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/Paperwork Act Notice.)

NAME OF BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

1a. GIVE THE DATE YOUR FARM RESIDENCE
OR OPERATION BEGAN OUTSIDE THE U.S.
2a. DO YOU OWN THE FARM?
YES

Form Approved
OMB No. 0960-0103

1b. GIVE THE DATE IT ENDED

1c. HOW DID IT END? (Sale, lease of land, etc.)

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

NO

(If "Yes," go on to question 3)
2c. EXPLAIN THE TYPE OF AGREEMENT OR CONTRACT YOU HAVE WITH THE OWNER
2d. HOW ARE YOU PAID? (Check one)
DAILY
3.

WEEKLY

MONTHLY

OTHER (Specify)

WHAT PHYSICAL OR MANAGEMENT SERVICES DO YOU PERFORM IN CONNECTION WITH 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
(Explain)

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 year.
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 currency)

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

ITEMS

PAGE 1

QUANTITY

AMT. RECEIVED
(local currency)

(over)

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

AMT. USED
ON FARM

AMOUNT
BARTERED

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

ITEM

AMT. USED
ON FARM

AMOUNT
BARTERED

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

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
(local 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

11a.

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

b.

RELATIONSHIP

DESCRIBE DUTIES PERFORMED

HOW ARE THEY PAID? (Check appropriate box or boxes)
CROP OR
LIVESTOCK SHARE

CASH WAGE

ROOM AND
BOARD

OTHER
(Specify)

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

1.
2.

1. Present
2. Last

Veterinary fees

1.
2.

Taxes and interest on
farm notes

1.
2.

1. Present
2. Last

Machine hire

1.
2.

Other expenses
(Specify below)

1.
2.

1. Present
2. Last

Farm supplies and cost
of repairs

1.
2.

1.
2.

REMARKS: (This space may be used for any additional information you may wish to give)

Knowing that anyone making a false statement or representation of a material fact in application or for use in determining
a right to payment under the Social Security Act commits a crime punishable under Federal law, I certify 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.

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

1. SIGNATURE OF WITNESS

SIGN
HERE

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)

STREET ADDRESS

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

PAGE 3

PRIVACY ACT/PAPERWORK ACT NOTICE

See Revised Privacy Act Statement Attached
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 to 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
to 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.

See Revised PRA Statement Attached
PAPERWORK REDUCTION ACT STATEMENT: The Paperwork Reduction Act of 1995 requires
us to notify you that this information collection meets the clearance requirements of 44 U.S.C.
§3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and
Budget control number. We estimate that it will take you about 60 minutes to read the
instructions, gather the necessary facts, and answer the questions.

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

PAGE 4

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 403(b), 403(c), and 405(a) of the Social Security Act, as amended, authorize us to
collect this information. The information you provide will be used to confirm past and
continuing entitlement to benefits and to determine whether such benefits are subject to
deductions.
The information you furnish on this form is voluntary. However, failure to provide this
requested information could prevent an accurate and timely decision on your claim and could
result in the loss of some benefits.
We rarely use the information you supply for any purpose other than for making a determination
about your continuing entitlement to benefits. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not limited to
the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for Federally-funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records
Notices entitled, Master Beneficiary Record, 60-0090 and Supplemental Security Income
Record, 60-0103. These notices, additional information regarding this form, and information
regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your
local 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 60 minutes to read the instructions, gather
the facts, and answer the questions. Send only comments relating to our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.