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

7162

FORM APPROVED
OMB NO. 0960-0049

SOCIAL SECURITY ADMINISTRATION

REPORT TO THE 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.

2.

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

.

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.

Has there been a change in your citizenship or your country of residence that you have
not yet reported to SSA?

YES

NO

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

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

(For SSA Use Only)
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.

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.

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).

a vaild 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
6401 Security Blvd, Baltimore, MD 21235-6401 USA. Send
only comments relating to our time estimate to this address,
not the completed form.

Explanations about these and other reasons why information

yousee
provide
us may be used or given out are available in Social
Please
revised
Security Offices. If you want to learn more about this, contact
Paperwork
The information provided will be used to confirm past and
any Social Security office.
continuing entitlement to benefits and may be disclosed by SSA
Reduction
Act and
to another governmental agency for the following purposes: (1)
Paperwork Reduction Act Statement - This information
to assist SSA in establishing the right of an individual to Social
collection
Privacy
Act meets the requirements of 44 U.S.C. § 3507, as
Security coverage and/or benefits; (2) to facilitate statistical
amended by section 2 of the Paperwork Reduction Act of 1995.
research and audit activities necessary to assure the integrity
You do notbelow.
need to answer these questions unless we display
Statements

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
Form SSA-7162-OCR-SM (5-2009) 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 OF 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.
(d) Enter date event occurred
(a)

5.

Marriage

(b)

Divorce

(c)

(Month-Day-Year)

Annulment

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:
the year before last
and

No

$
$

last year
also give

$

your estimate of earnings for this year

6.

Yes

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

(Month-Day-Year)

(b) Date child returned
(Month-Day-Year)

(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 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.

7.

Signature or mark of payee (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 (5-2009)

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 5
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-7162 – Foreign Enforcement Questionnaire (Beneficiary)
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 you Social Security benefits. Your response is voluntary. However, failure to provide the
requested information may prevent us from making an accurate and timely decision on your claim, 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
any U.S. Embassy, consulate, VARO or U.S. Social Security office.