SOCIAL SECURITY ADMINISTRATION
Form Approved OMB No. 0960-0050
QUESTIONNAIRE ABOUT EMPLOYMENT OR SELF-EMPLOYMENT OUTSIDE THE UNITED STATES (See Reverse for Privacy Act Notice)
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.
NAME AND ADDRESS OF EMPLOYER (IF SELF-EMPLOYED, SHOW "SELF"AND ADDRESS OF YOUR TRADE OR BUSINESS.)
TYPE OF BUSINESS DATE BEGAN (Month, Day, Year) DATE ENDED (Month, Day, Year) (IF NOT ENDED, PRINT "NOT 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? (If "No," go on to item 4.) Yes No (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. $ 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? Yes No (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) 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.)
Form SSA-7163 (8-2001) Destroy Prior Editions EF (9-2001) (If you need more space use the REMARKS section on the reverse.)
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 filing in REMARKS.
$ $ $
$ $ $
$ $ $
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.)
ALWAYS COMPLETE THIS PORTION I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment or both. I affirm that all information I have given in this document is true.
SIGNATURE OF BENEFICIARY
7. SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
(MONTH, DAY, YEAR)
TELEPHONE NUMBER(S) AT WHICH YOU MAY BE CONTACTED DURING THE DAY (Include Area Code)
MAILING ADDRESS (NUMBER & STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
ENTER NAME OF COUNTRY IN WHICH YOU NOW LIVE.
Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the claimant must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS ADDRESS (No. and street, city, country and postal code) 2. SIGNATURE OF WITNESS ADDRESS (No. and street, city, country and postal code)
PRIVACY ACT/PAPERWORK ACT NOTICE STATUTORY AUTHORITY: This form requests information under the authority of Section 205 of the Social Security Act. MANDATORY OR VOLUNTARY: It is mandatory that you furnish the information if, while under your full retirement age, you received a benefit for any month (1) in which you engaged in noncovered employment or self-employment outside the United States for more than 45 hours or (2) which is in a year when your total earnings from covered employment and self-employment exceeded the annual earnings limitation set by law. EFFECT: Failure to complete this form within a reasonable time will constitute justification for a determination that your benefits are subject to deductions for such months as may be specified by the Social Security Administration. PURPOSE: The information is needed to determine whether work deductions are applicable under Section 203 of the Social Security Act. OTHER ROUTINE USES: Other uses which may be made of the information are: (1) to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the Social Security programs; and (2) to comply with Federal laws requiring the exchange of information between SSA and another agency. We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this contact any Social Security office. PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 12 minutes to read the instructions, gather the necessary facts and answer the questions.
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.)