Free Supplemental Satement Regarding Farming Activities of Person Outside US - Federal

. SOCIAL SECURITY ADMINISTRATION

TOE 220 SUPPLEMENTAL STATEMENT REGARDING FARMING ACTIVITIES OF PERSON LIVING OUTSIDE THE U.S.A. (This statement is to be completed by a beneficiary living on a farm or operating a farm outside the United States.) (See Page 4 for Privacy Act/Paperwork Act Notice.)
SOCIAL SECURITY CLAIM NUMBER

Form Approved OMB No. 0960-0103

NAME OF BENEFICIARY

1a. GIVE THE DATE YOUR FARM RESIDENCE OR OPERATION BEGAN OUTSIDE THE U.S. 2a. DO YOU OWN THE FARM? YES NO

1b. GIVE THE DATE IT ENDED

1c. HOW DID IT END? (Sale, lease of land, etc.)

2b. GIVE NAME OF THE OWNER AND INDICATE HIS RELATIONSHIP TO YOU

(If "Yes," go on to question 3) 2c. EXPLAIN THE TYPE OF AGREEMENT OR CONTRACT YOU HAVE WITH THE OWNER 2d. HOW ARE YOU PAID? (Check one) DAILY 3. WEEKLY MONTHLY OTHER (Specify)

WHAT PHYSICAL OR MANAGEMENT SERVICES DO YOU PERFORM IN CONNECTION WITH THE FARM?

4a. WHAT IS THE LAND AREA OF THE FARM?

4b. HOW MUCH OF THIS LAND IS USED FOR (1) GROWING CROPS (2) GRAZING ANIMALS (3) ORCHARDS (Olive, fig, or other food-bearing trees or vines) (4) OTHER (Explain)

Answer Questions 5 through 12 if you own or operate the farm. Be sure to sign this statement. 5. Give below the types and quantity of livestock, poultry, crops, and produce RAISED on the farm in the present year and last year.
PRESENT YEAR a. TYPES OF LIVESTOCK AND POULTRY NO. OF HEAD LAST YEAR TYPES OF LIVESTOCK AND POULTRY NO. OF HEAD

b.

TYPES OF CROPS

LAND AREA USED

YIELD

TYPES OF CROPS

LAND AREA USED

YIELD

6. Give below the following information about the livestock, poultry, crops, and produce SOLD.
PRESENT YEAR ITEMS QUANTITY AMT. RECEIVED (local currency) ITEMS LAST YEAR QUANTITY AMT. RECEIVED (local currency)

Form SSA-7163A-F4 (8-2001) Destroy Prior Editions EF (9-2001)

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(over)

7. Give below the following information about livestock, poultry, crops or produce which the family used or bartered.
PRESENT YEAR
ITEM AMT. USED ON FARM AMOUNT BARTERED AMT. AND KIND OF GOODS AND/OR SERVICES RECEIVED IN EXCHANGE FOR BARTERED GOODS ITEM AMT. USED ON FARM

LAST YEAR
AMOUNT BARTERED AMT. AND KIND OF GOODS AND/OR SERVICES RECEIVED IN EXCHANGE FOR BARTERED GOODS

8. Give below the following information about other income or payments received from your farming operation (such as government agricultural program payments, patronage dividends, breeding fees, etc.)
PRESENT YEAR TYPE OF INCOME AMOUNT RECEIVED (local currency) LAST YEAR TYPE OF INCOME AMOUNT RECEIVED (local currency)

9. Give description and age of farm equipment or machinery you have (such as tractor, wagon, truck, etc.) (If none, show none.)

10.What animals do you have to work the farm? (If none, show none.)

Form SSA-7163A-F4 (8-2001) EF (9-2001)

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11a.

Give the name and relationship to you (if any) of each person working on the farm.
NAME RELATIONSHIP DESCRIBE DUTIES PERFORMED

b.

HOW ARE THEY PAID? (Check appropriate box or boxes) CROP OR LIVESTOCK SHARE CASH WAGE ROOM AND BOARD OTHER (Specify)

12.List expenses (in local currency) for the present year and last year. (Do not include material supplied by Government agencies.)
YEAR TYPE OF EXPENSE COST TYPE OF EXPENSE COST

1. Present 2. Last 1. Present 2. Last 1. Present 2. Last 1. Present 2. Last 1. Present 2. Last

Labor hired

1. 2. 1. 2. 1. 2. 1. 2. 1. 2.

Electricity, gasoline and other fuel Livestock and poultry purchased Taxes and interest on farm notes Other expenses (Specify below)

1. 2. 1. 2. 1. 2. 1. 2. 1. 2.

Feed, seeds and fertilizer purchased Veterinary fees

Machine hire

Farm supplies and cost of repairs

REMARKS: (This space may be used for any additional information you may wish to give)

Knowing that anyone making a false statement or representation of a material fact in application or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law, I certify that the above statements are true.
If this statement has been signed by mark (x), or fingerprint, two witnesses who know the signer must sign below, giving their full addresses. 1. SIGNATURE OF WITNESS ADDRESS OF WITNESS (Street number, city and country) SIGNATURE OF PERSON COMPLETING THIS STATEMENT (First name, middle initial, last name) (Write in ink) SIGN HERE STREET ADDRESS

2. SIGNATURE OF WITNESS ADDRESS OF WITNESS (Street number, city and country)

CITY, COUNTRY, POSTAL CODE DATE (Month, day and year)

Form SSA-7163A-F4 (8-2001) EF (9-2001)

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PRIVACY ACT/PAPERWORK ACT NOTICE


The information requested on this form is sought pursuant to the authority granted in 42 U.S.C. 403(b), 403(c), and 405(a). The information provided will be used to confirm past and continuing entitlement to benefits and to determine whether such benefits are subject to deductions. Other uses which may be made of the information are summarized below. Failure to provide all or any part of the requested information is cause for suspension of benefit payments. It is required that an individual under full retirement age receiving retirement insurance benefits report any noncovered work which he or she engaged in outside the United States. The failure to report these events may result in penalty deductions being made from benefit payments. This notice is given pursuant to section 3 of the Privacy Act of 1974. If you need help in completing this form, the people at any U.S. Embassy or consular post will be glad to help you.

OTHER USES WHICH MAY BE MADE OF THE INFORMATION
The information you furnish on this form may be disclosed by SSA to another governmental agency for the following purposes: 1. To assist SSA in establishing the right of an individual to Social Security coverage and/ or benefits; 2. To facilitate statistical research and audit activities necessary to assure the integrity and improvement of the Social Security programs; and 3. To comply with Federal laws requiring the exchange of information between SSA and another agency.

PAPERWORK REDUCTION ACT STATEMENT: The Paperwork Reduction Act of 1995 requires us to notify you that 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 60 minutes to read the instructions, gather the necessary facts, and answer the questions.

Form SSA-7163A-F4 (8-2001) EF (9-2001)

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