Questionnaire About Employment Or Self-Employment Outside The United States

Justification for Non-Substantive Changes for Form SSA-7163

QUESTIONNAIRE ABOUT EMPLOYMENT OR SELF-EMPLOYMENT OUTSIDE THE UNITED STATES

20 CFR 404.415 and 404.417

OMB No. 0960-0050

Background

SSA uses Form SSA-7163, Questionnaire About Employment or Self-Employment Outside the United States, to determine continuing eligibility for benefits and whether those benefits are subject to deductions under the Foreign Work Test (FWT). Currently, the paper and PDF versions of this form include a signature requirement.

We recently reassessed the need for the respondent’s signature on this form and determined that we no longer require it. Therefore, we are removing the signature requirement from this form.

Revision to the Information Collection

• Change #1: We are removing the signature requirement from Form SSA-7163.

Justification #1: We reassessed the need for a wet signature on this form and determined we no longer require it. Therefore, we will no longer ask respondents to sign this form prior to submitting it to SSA.

• Change #2:  We are replacing the Penalty of Perjury Statement with a Penalty of Perjury Warning: 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.

Justification #2:  The Penalty of Perjury Statement is directly connected to the signature and needs to be removed since a signature is no longer required. However, to maintain the intent of that statement, it will be replaced with a Penalty of Perjury Warning.

• Change #3: On page 2 of the form, we are making minor revisions to the contact information fields and removing the fields for witnesses to complete.

Justification #3:  The contact information fields need to be revised and the witness information fields need to be removed since the form no longer requires a signature.

After OMB approves the signature removal for this form, we will implement the new version of the form that clarifies that we no longer require a signature by revising the signature block.

This action will not affect the public reporting burden.