Form SSA-7161-OCR-SM Report to United States Social Security Administration b

Form SSA-7161-OCR-SM (XX-XXXX)
Discontinue Prior Editions
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Social Security Administration
OMB No. 0960-0049
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.
YES
NO
Has anyone for whom you receive benefits changed his/her citizenship or country of
3.
residence in the past 15 months?
4.

Has anyone for whom you receive benefits married, had a divorce (or annulment) or
died in the past 15 months?

5.

Has the parent (natural, adoptive or stepparent) or 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.)

6.

Did anyone for whom you receive benefits work for someone else or own a business
or farm in the past 15 months?

7.

Did anyone for whom you receive benefits live apart from you during any of the
past 15 months?

DO NOT COMPLETE ITEMS 8 THROUGH 10 IF YOU MEET THE CONDITIONS DESCRIBED IN THE
INSTRUCTIONS PAGE
8.

9.

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 themself) 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.

Continued on the reverse

Form SSA-7161-OCR-SM (XX-XXXX)
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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.
(a) Name of person
(d) Current country (e) Date residence
(b) Country of new (c) Date
acquired
of residence
began
citizenship
4. If you answered "Yes" to question 4 on the other side, complete the information below.
(b) Check which event occurred
(a) Name of person
Marriage
Annulment
Death
Divorce

(c) Date event
occurred

5. If you answered "Yes" to question 5 on the other side, complete the information below.
(b) Check which event occurred
(a) Name of parent
Marriage
Annulment
Death
Divorce

(c) Date event
occurred

6. If you answered "Yes" to question 6 on the other side, complete the information below.
(b) Check one
(a) Name of person
Employee
Self-Employed

(c) Date work
began

(d) If ended, enter date work stopped (e) List each month they worked 45 hours or less (Explain in
Remarks)
(f) Was this work done in the United States (g) If you answered "Yes to (f), enter
or did they pay United States Social
their total earnings for last year
$
Security taxes on earnings from this work?
AND give your estimate of this year's
earnings.
No
Yes
$
7. If you answered "Yes" to question 7 on the other side, complete the information below.
(a) Name of beneficiary who did (b) Date beneficiary (c) Reason for leaving
not live with you
left

(d) Date beneficiary
returned

(e) If you listed someone in (a) above who has not returned, enter the address where they 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 beneficiary (Note: If this form is signed with a mark, a witness Date
must sign below).
12. Signature of witness

Date

Form SSA-7161-OCR-SM (XX-XXXX)

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Privacy Act Statement
Collection and Use of Personal Information
Sections 203, 205, and 1631 of the Social Security Act, as amended, allow us to collect this
information, which we will use to determine continued eligibility for benefits and to monitor
representative payee performance. Providing this information is voluntary, but not providing
all or part of the information may prevent an accurate and timely decision on any claim filed.
As law permits, we may use and share the information you submit, including with other
Federal agencies, contractors, and others, as outlined in the routine uses within System of
Records Notices (SORN) 60-0089 and 60-0320, available at www.ssa.gov/privacy. The
information you submit may also be used in computer matching programs to establish or
verify eligibility for Federal benefit programs and to recoup 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 control number. We
estimate that it will take about 20 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.