Current SSA-7161-INST

Form SSA-7161-INST (07-2023)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0049

INSTRUCTIONS FOR COMPLETION OF FORM SSA-7161-OCR SM
WHAT YOU NEED TO DO
First please read the instructions below. This is important
because not all questions are self-explanatory. Then,
complete your report and return it to the Social Security
Administration, P.O. Box 7161, Wilkes-Barre, Pennsylvania,
18767-7161, U.S.A. in the enclosed envelope within 60 days
from the day you receive it. If you do not return it promptly, we
may stop sending payments to you.
GENERAL INSTRUCTIONS
To help us process your report and avoid having to recontact
you, please follow these instructions.
• Use black ink or a dark pencil to complete the report.
• Please print your answers, except in the signature block.
• Place "X's" in the appropriate "Yes" or "No" boxes on the
first page.
• On the first page, keep your "X's" inside the boxes.
• You must sign the form on the back page.
HOW TO FILL OUT THE FORM
The numbers below match the numbered questions on the
report.
Item 1. Do not write in this space if the preprinted address in
the box is correct. If the preprinted address is incorrect and
you have not reported your new address to the Social Security
Administration, then print the correct address in this space.
Item 2. Enter the telephone number at which you may be
contacted during the day in this space.
Item 3. Has anyone for whom you receive benefits changed
his/her citizenship or country of residence in the past 15
months? If not, place an "X" in the "NO" box and go on to item
4. If yes, place an "X" in the "YES" box and turn the form over.
In item 3 on the back, enter in:
(a) the name of the person;
(b) the country of new citizenship;
(c) the date the new citizenship was acquired; and/or
(d) the current country of residence;
(e) the date residence began.
Item 4. Has anyone for whom you receive benefits married,
had a divorce (or annulment) or died in the past 15 months? If
not, place an "X" in the "NO" box and go on to item 5. If yes,
place an "X" in the"YES" box and turn the form over. In item 4
on the back, enter in:
(a) the name of the person;
(b) a check mark next to which event occurred;
(c) the date the event occurred.
Item 5. Has the parent (natural, adoptive or stepparent) of any
child for whom you receive benefits died, married, or had a
divorce (or annulment) in the past 15 months?

(Note that it is not necessary that the parent have been
receiving benefits.) If not, place an "X" in the "NO" box and go
on to item 6. If yes, place an "X" in the "YES" box and turn the
form over. In item 5 on the back, enter in:
(a) the name of the parent;
(b) a check mark next to which event occurred;
(c) the date the event occurred.
Item 6. Did anyone for whom you receive benefits work for
someone else or own a business or farm in the past 15
months? If not, place an "X" in the "NO" box and go on to Item
7. If yes, place an "X" in the "YES" box and turn the form over.
In item 6 on the back, enter in:
(a) the name of the person who worked or owned a
business or farm;
(b) a check mark in the first block if he/she worked for
someone else or a check mark in the second block if he/
she was self-employed;
(c) the month, day, and year the work began;
(d) if the work has ended, enter the month, day, and year
the work ended. If not ended, write "Not Ended";
(e) list each month in the work period indicated in (c) and (d)
above that he/she worked 45 hours or less. (Explain in
"Remarks" why his/her employment/self-employment
calls for 45 hours or less);
(f) if the work was done in the U.S. or if U.S. Social Security
taxes (FICA) were paid on earnings from this work, check
the "Yes" block. If not, check the "No" block;
(g) if the answer in (f) above was "Yes" enter his/her total
earnings for the last year in the first space and give an
estimate of this year's earnings in the next space.
Item 7. Did any person for whom you receive benefits live
apart from you during any of the past 15 months? If not, place
an "X" in the "NO" box and go on to item 8. If yes, place an
"X" in the "YES" box and turn the form over. In item 7 on the
back, enter in:
(a) the name of the person who did not live with you;
(b) the date he/she left;
(c) the reason for leaving
(d) the date he/she returned. If he/she has not returned,
enter "Not returned";
(e) the address where he/she can be reached.
Item 8. Did you give the Social Security check or the full
amount of the benefits to another person (for example, the
beneficiary's custodian or the beneficiary himself) during the
past 15 months? If not, place an "X" in the "NO" box and go
on to item 9. If yes, place an "X" in the "YES" box and turn the
form over. In item 8 on the back, show to whom the funds
were given (the custodian, the beneficiary, etc.).

Form SSA-7161-INST (07-2023)
Discontinue Prior Editions
Social Security Administration
Item 9. Were all of the Social Security benefits received
during the past 15 months used for the beneficiary and/or held
for the beneficiary? If all the benefits were used or, if all were
not used, but the remainder were held for the beneficiary,
place an "X" in the "YES" box and go on to item 10. If not,
place an "X" in the "NO" box, turn the form over and explain in
"Remarks" what was done with the benefits.
Item 10. A. Show the manner in which any amounts not used
for the beneficiary are being held. If the benefits are not in a
bank account, check "Other" and explain in "Remarks" on the
back. B. Show the title or ownership of the account in which
the amounts are held.
BE SURE TO TURN THE FORM OVER AND ENTER YOUR
SIGNATURE (OR MARK) AND THE DATE IN ITEM 11. IF
YOU SIGN WITH A MARK, A WITNESS MUST COMPLETE
ITEM 12. IF A WITNESS SIGNS THE FORM, HE/SHE
SHOULD ENTER HIS/HER NAME, ADDRESS, AND THE
DATE IN ITEM 12.

ALL KINDS OF WORK SHOULD BE REPORTED
Every kind of work, trade, apprenticeship or business in which
the beneficiary engages while the beneficiary is under age 66
MUST BE REPORTED. After you notify us of work, we will
inform you if the work has any effect on benefits.

YOUR RESPONSIBILITY AS A REPRESENTATIVE PAYEE
Your job is to use the Social Security benefits you receive for
the personal care and well-being of the beneficiary. This is
true whether you are a relative, friend, court-appointed
guardian, or official of a private agency or institution. You
must keep yourself informed of the beneficiary's needs so you
can decide how the benefits should be used. You must
account for the use of the benefits on the form enclosed. This
accounting will be reviewed by the Social Security
Administration and is subject to verification. Therefore, you
should keep a record of the amount of benefits you received
and how you used them (keep receipts, canceled checks,
etc.).

You must notify the Social Security Administration when the
beneficiary changes residence or you are no longer
responsible for the care and welfare of the beneficiary. You
must also report to us promptly if the beneficiary dies, marries,
is adopted, goes to work, or enters or leaves a hospital or
institution.

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