Form SSA-7162-OCR-SM Report to United States Social Security Administration

Form SSA-7162-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
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
2. Telephone number at which you
below.
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 8 ON THE BACK OF THIS FORM.
YES
3.

NO

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

4.

Have you married or had a divorce or annulment since you last reported your marital
status to SSA?

5.

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.

Continued on the reverse

Form SSA-7162-OCR-SM (XX-XXXX)
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IF YOU 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 8, SIGN, DATE AND
RETURN THE FORM.
3. If you answered "Yes" to question 3 on the other side, complete the information below.
(c) Date acquired (MM/DD/YYYY)
(a) Country of new citizenship
(b) Current country of residence

(d) Date of change (MM/DD/YYYY)

4. If you answered "Yes" to question 4 on the other side, complete the information below.
(d) Enter date event occurred
(MM/DD/YYYY)
Annulment
(a)
Marriage
(b)
Divorce
(c)
5. If you answered "Yes" to question 5 on the other side, complete the information below.
(b) Date work began
(a) Check one
(c) If ended, enter date work
(MM/DD/YYYY)
stopped (MM/DD/YYYY)
Employee
Self-Employed
(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?

No

Yes

(f) If you answered "Yes to (e) above enter your total earnings for:
the year before last and

$

last year also give

$

your estimate of earnings for this year

$
6. If you answered "Yes" to question 6 on the other side, complete the information below.
(a) Date child left
(MM/DD/YYYY)

(b) Date child returned (c) Name of child
(MM/DD/YYYY)

(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 beneficiary (Note: If this form is signed with a mark, a
Date
witness must sign below).
8 Signature of witness

Date

Form SSA-7162-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.