Form SSA-7163 Questionnaire About Employment Or Self-Employment Outsid

Form SSA-7163 (XX-XXXX) UF
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Social Security Administration

Page 1 of 3
OMB No. 0960-0050

QUESTIONNAIRE ABOUT EMPLOYMENT OR SELF-EMPLOYMENT OUTSIDE THE UNITED STATES
(See Page 3 for Privacy Act Statement)
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
Type of business
Name and address of employer (if self-employed, show (such as e.g. farming,
Date ended (MM/DD/YYYY)
Date began
"SELF" and address of your trade or business.)
doctor, truck driver,
(if not ended, print "NOT
(MM/DD/YYYY)
etc.)
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:
Month

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)

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.)
Year

Total wages (as shown on U.S. Form W-2 before payroll deductions)
$
$
$

(b) If you are now employed, please submit an estimate of the gross wages (before payroll deductions) you expect to earn this
year. $

Form SSA-7163 (XX-XXXX) UF

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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?
(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)

Yes

No

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.)
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.)

Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in determining a
payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or
continued right to payment, or submits or causes to be submitted any false statement or document knowing the same to contain
any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be
subject to administrative sanctions.
Contact Information Of Person Making Statement
7. First Name, Middle Initial, Last Name

Date: MM/DD/YYYY

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

Enter name of country in which you now live.

Postal Code

Form SSA-7163 (XX-XXXX) UF

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Privacy Act Statement
Collection and Use of Personal Information
Sections 203(b) and (c) and 205 of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent an accurate and timely decision on any claim filed.
We will use the information to determine if work deductions are applicable to any claim filed.
We may also share your information for the following purposes, called routine uses:
• To the Department of State for administering the Social Security Act in foreign countries through services
and facilities of that agency; and
• To the Social Security Agency of a foreign country, to carry out the purpose of an international Social
Security agreement entered into between the United States and the other country, pursuant to section 233
of the Social Security Act.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0059,
entitled Earnings Recording and Self-Employment Income System, as published in the Federal Register
(FR) on January 11, 2006, at 71 FR 1819 and 60-0089, entitled Claims Folders Systems, as published in
the FR on October 31, 2019, at 84 FR 58422. Additional information, and a full listing of all of our SORNs, is
available on our website at www.ssa.gov/privacy.

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 60 minutes to
read the instructions, gather the facts, and answer the questions. Send only comments regarding this
burden estimate or any other aspect of this collection, including suggestions for reducing this
burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
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.)