Form SSA-7163 Questionnaire About employment or Self Employment Outsid

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0050

TOE 220

QUESTIONNAIRE ABOUT EMPLOYMENT OR SELF-EMPLOYMENT OUTSIDE THE UNITED STATES
(See Reverse for Privacy Act Notice)
PLEASE PRINT YOUR ANSWERS
NAME OF WORKER ON WHOSE ACCOUNT BENEFITS ARE BEING PAID

WORKER'S SOCIAL SECURITY CLAIM NUMBER

/
NAME OF EMPLOYED OR SELF-EMPLOYED BENEFICIARY

/

BENEFICIARY'S SOCIAL SECURITY NUMBER (If different from
worker's)

/

/

1. Give the following information about your employment or self-employment outside the United States.
Work Period
NAME AND ADDRESS OF EMPLOYER (IF SELF-EMPLOYED, SHOW
"SELF"AND ADDRESS OF YOUR TRADE OR BUSINESS.)

TYPE OF BUSINESS
DATE BEGAN
(Month, Day, Year)

DATE ENDED (Month, Day, Year) (IF
NOT ENDED, PRINT "NOT ENDED".)

2. List any month(s) of the work period(s) shown in item 1 in which you worked 45 hours or less and explain fully:
EXPLANATION OF WHY YOU WERE EMPLOYED OR SELF-EMPLOYED 45 HOURS OR LESS IN MONTH(S) LISTED. (If your
employment agreement calls for work of 45 hours or less a month, attach a copy of the agreement or a written statement from your
employer explaining the terms of the agreement)

MONTH

IF YOU WORKED AS AN EMPLOYEE FOR WAGES DURING A WORK PERIOD SHOWN IN ITEM 1, ANSWER QUESTION
3. IF NOT, SKIP TO ITEM 4.
3. (a) Was the employment covered under the United States Social Security program; i.e., were the wages subject to
United States FICA taxes?
Yes
No
(If "No," go on to item 4.)
(If "Yes," enter the total amount of wages earned during each year of the work period.)
TOTAL WAGES (AS SHOWN ON U.S. FORM W-2 BEFORE PAYROLL DEDUCTIONS)

YEAR

$
$
$
(b) If you are now employed, please submit an estimate of the gross wages (before payroll deductions) you expect
to earn this year. $
IF YOU WERE SELF-EMPLOYED DURING THE WORK PERIOD SHOWN IN ITEM 1, ANSWER QUESTION 4.
If not, skip to item 7.
4. (a) While self-employed outside the United States, were you either a legal resident of the United States or a United
States citizen? (If "Yes", answer item 4(b). If "No", go on to item 7.)
Yes
No
(b) If you had the option to elect Social Security coverage under a program other than the United States Social
Security program, did you elect such coverage?
Yes
No
(If "No," answer items 5 and 6. If "Yes," list the country under whose program you elected coverage and go on
to item 7.)
(country)
5. Did you file income tax returns with the United States Internal Revenue Service for all years shown in item 1?
Yes
No
(If "Yes", attach a copy of Schedule C (or F) and SE and Form 2555 of your United States Income Tax Return filed
for each year of the work period shown in item 1. If your earnings derived from a partnership, attach a copy of
Form 1065.)
Form SSA-7163 (8-2001) Destroy Prior Editions EF (9-2001)

(If you need more space use the REMARKS section on the reverse.)

If you answer "No" to question 5, furnish a breakdown of your gross receipts, business expenses, and net earnings for
each year shown in item 1 and explain your reason for not filling in REMARKS.
YEAR

GROSS EARNINGS

BUSINESS EXPENSES

NET EARNINGS

$

$

$

$

$

$

$

$

$

6. If you are now self-employed, show how much you expect your net earnings to be for the current year.
$
REMARKS: (This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)

ALWAYS COMPLETE THIS PORTION
I know that anyone who makes or causes to be made a false statement or representation of material fact in an
application or for use in determining a right to payment under the Social Security Act commits a crime punishable under
Federal law by fine, imprisonment or both. I affirm that all information I have given in this document is true.
SIGNATURE OF BENEFICIARY

DATE SIGNED

7. SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)

(MONTH, DAY, YEAR)

MAILING ADDRESS (NUMBER & STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)

TELEPHONE NUMBER(S) AT WHICH YOU MAY BE
CONTACTED DURING THE DAY (Include Area Code)

CITY

POSTAL CODE

ENTER NAME OF COUNTRY IN WHICH YOU NOW LIVE.

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the claimant must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

ADDRESS (No. and street, city, country and postal code)

ADDRESS (No. and street, city, country and postal code)

PRIVACY ACT/PAPERWORK ACT NOTICE
STATUTORY AUTHORITY: This form requests information under the authority of Section 205 of the Social Security Act.
MANDATORY OR VOLUNTARY: It is mandatory that you furnish the information if, while under your full retirement age, you received a benefit for any month (1) in which you engaged in
noncovered employment or self-employment outside the United States for more than 45 hours or (2) which is in a year when your total earnings from covered employment and self-employment
exceeded the annual earnings limitation set by law.
EFFECT: Failure to complete this form within a reasonable time will constitute justification for a determination that your benefits are subject to deductions for such months as may be specified by
the Social Security Administration.
PURPOSE: The information is needed to determine whether work deductions are applicable under Section 203 of the Social Security Act.
OTHER ROUTINE USES: Other uses which may be made of the information are: (1) to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the
Social Security programs; and (2) to comply with Federal laws requiring the exchange of information between SSA and another agency.
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 Privacy Act and PRA Statements Attached

PAPERWORK REDUCTION ACT: 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 12 minutes to read the instructions, gather
the necessary facts and answer the questions.

EXPLANATION OF TERMS USED IN THIS QUESTIONNAIRE
1. United States - Include the 50 States, District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, and American Samoa.
2. Resident - You are a resident of a country if you make your temporary or permanent home there. (Visiting as a tourist, or on a short business trip,
does not establish residence in a country. But going into a country, setting up permanent quarters there for yourself and your family, and settling
down in the community generally make you a resident of that country even though you intend to return eventually to another country which you
consider to be your permanent home.)

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 203 and 205 of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to determine applicable work deductions.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making an accurate and timely decision on your benefits.
We rarely use the information you supply us for any purpose other than to determine continued
eligibility of Social Security benefits. However, we may use the information for the
administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices 60-0059, entitled, Earnings Recording
and Self-Employment Income System and 60-0089, entitled, Claims Folders Systems.
Additional information about these and other system of records notices and our programs are
available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
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
(OMB) control number. We estimate that it will take about 12 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