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 THE 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.

2.

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

.

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.

3.
4.
5.

6.
7.
8.

9.

Has anyone for whom you receive benefits changed his/her citizenship or country
of residence in the past 15 months?

YES

NO

YES

NO

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/herself) during the past 15 months?

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. 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 (5-2009) Destroy Prior Editions

(FOR SSA USE ONLY)
SSN
7161

Continued on the
Reverse

IF YOU ANSWERED “YES” TO ANY OF THE 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
Marriage
Annulment
Divorce
Death

(b) Check which event occurred
Marriage
Annulment
Divorce
Death

(c) Date event
occurred

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.

(c) Date event
occurred

If you answered “Yes” to question 5 on the other side, complete the information below.
(a) Name of parent

6.

(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 bene- (c) Reason for leaving
ficiary left

(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 of 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.)

Date

12.

Signature of witness

Date

Form SSA-7161-OCR-SM (5-2009)

Address (include ZIP code)

SSA will insert the following revised PRA Statement 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. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.

SSA-7161 – Foreign Enforcement Questionnaire (Rep Payee)
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
The United States Code of Federal regulations (42 U.S.C. § 403(c), 403(g), 405(a) and 405(j)) authorize us
to collect the information on this form. The information you provide will be used to determine if we can
continue to pay Social Security benefits on this claim. Your response is voluntary. However, failure to
provide the requested information may prevent us from making an accurate and timely decision, or could
result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for determining the
continued entitlement to benefit payments. However, in accordance with 5 U.S.C. § 552a(b) of the Privacy
Act, we may disclose the information provided on this form (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 make determinations
for eligibility in similar health and income maintenance programs at the Federal, State, and local level; (3) to
comply with Federal laws requiring the disclosure of the information from our records; and (4) to facilitate
statistical research, audit or investigative activities necessary to assure the integrity of SSA programs.
We may also use the information you provide when we match records by computer. Computer matching
programs compare our records with those of 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 contained in our System of Records Notice 60-0089
(Claims Folders System). Additional information regarding this form and our other system of records
notices and Social Security programs are available from our Internet website at www.socialsecurity.gov or at
your local any U.S. Embassy, consulate, VARO or U.S. Social Security office.