Form SSA-7161-OCR-SM an SSA-7161-OCR-SM an Report to U.S. SSA by Person Receiving Benefits for a Ch

7161

FORM APPROVED
OMB NO. 0960-0049

SOCIAL SECURITY ADMINISTRATION

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.

3.
4.
5.

6.
7.
8.

9.

Has anyone for whom you receive benefits changed his/her citizenship or country
of residence in the past 15 months?

YES

NO

YES

NO

Has anyone for whom you receive benefits married, had a divorce
(or annulment) or died in the past 15 months?
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? (It is not necessary that the parent have been receiving benefits.)

Did anyone for whom you receive benefits work for someone else or own a
business or farm in the past 15 months?
Did any person for whom you receive benefits live apart from you during
any of the past 15 months?
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
himself/herself) 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.
Form SSA-7161-OCR-SM (5-2009) Destroy Prior Editions

(FOR SSA USE ONLY)
SSN
7161

Continued on the
Reverse

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.
(b) Country of new
citizenship

(a) Name of person

4.

(b) Check which event occurred
Marriage
Annulment
Divorce
Death

(b) Check which event occurred
Marriage
Annulment
Divorce
Death

(c) Date event
occurred

If you answered “Yes” to question 6 on the other side, complete the information below.
(b) Check one
Employee

(a) Name of person

(d) If ended, enter date work stopped

Yes

No

SelfEmployed

(c) Date work
began

(e) List each month that he/she worked 45 hours or less (Explain in Remarks)

(f) Was this work done in the United States or
did he/she pay United States Social
Security taxes on earnings from this work?

7.

(c) Date event
occurred

If you answered “Yes” to question 5 on the other side, complete the information below.
(a) Name of parent

6.

(e) Date residence
began

If you answered “Yes” to question 4 on the other side, complete the information below.
(a) Name of person

5.

(c) Date
(d) Current country
acquired
of residence

(g) If you answered “Yes” to (f), enter his/her
$
total earnings for last year
AND give your estimate of this
year's earnings.

$

If you answered “Yes” to question 7 on the other side, complete the information below.
(a) Name of beneficiary who did not
live with you

(b) Date bene- (c) Reason for leaving
ficiary left

(d) Date beneficiary returned

(e) If you listed someone in (a) above who has not returned, enter the address where he/she 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 payee (Note: If this form is signed with a mark, a witness must sign below.)

Date

12.

Signature of witness

Date

Form SSA-7161-OCR-SM (5-2009)

Address (include ZIP code)

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 1631(d)(1), and 1631(e)(1) of the Social Security Act, as amended, authorize us
to collect this information. We will use the information you provide to determine continued
benefit eligibility.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may cause suspension or loss of additional benefits.
We rarely use the information for any purpose other than form making a decision regarding
continuing entitlement to benefits. However, we may use it for the administration and integrity
of our programs. We may also disclose the information to another person or to another agency in
accordance with approved routine uses, including, but not limited to the following:
1.

To enable a third party or an agency to assist us in establishing rights to our
benefits and coverage;

2.

To comply with Federal laws requiring the release of information from our
records (e.g., to the Government Accountability Office and Department of
Veterans Affairs);

3.

To make determinations for eligibility in similar heath and income maintenance
programs at the Federal, State, and local level; and,

4.

To facilitate statistical research, audit, and investigatory activities necessary to
assure the integrity and improvement of our programs (e.g., to the Bureau of the
Census and to private entities under contract with us).

We may also use the information you provide in computer matching programs. Matching
Programs compare our records with records kept by other Federal, State, or local
government agencies. We use the information from these programs to establish or verify
a person’s eligibility for federally funded and administered benefit programs and for
repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act Systems
of Records Notices entitled, Claims Folders Systems, 60-0089, and Electronic Disability
(eDib) Claim Folder, 60-0320. These notices, additional information regarding our
Programs and systems are available on-line at www.socialsecurity.gov or at your Social
Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 (OMB) control number. We estimate that it will take about
15 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 21235-0001.

7162

FORM APPROVED
OMB NO. 0960-0049

SOCIAL SECURITY ADMINISTRATION

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 below.

2.

Telephone number at which you 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 7 ON THE BACK OF THIS FORM.

3.
4.
5.

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

YES

NO

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

(For SSA Use Only)
SSN

See Revised Privacy Act Statement
PAPERWORK ACT AND PRIVACY ACT NOTICE
The information requested on this form is sought pursuant to
the authority granted in 42 U.S.C. 403(c), 403(g), 405(a) and
405(j). Your response to the questions on this form is required
for you to continue to receive benefits. Failure to report those
events which can cause suspension of benefits may cause
the loss of additional benefits.
The information provided will be used to confirm past and
continuing entitlement to benefits and 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; (3) to
comply with Federal laws requiring the exchange of
information between SSA and another agency; and (4) to
comply with Freedom of Information Act (5 U.S.C. 552).
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
Form SSA-7162-OCR-SM (5-2009) Destroy Prior Editions

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.

See Revised PRA

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 vaild Office of Management and Budget control number. We
estimate that it will take about 5 minutes to read the
instructions, gather the facts, and answer the questions.
You may send comments on our time estimate above to: SSA
6401 Security Blvd, Baltimore, MD 21235-6401 USA. Send
only comments relating to our time estimate to this address,
not the completed form.

7162

Continued on the
Reverse

IF YOU HAVE 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 7, SIGN, DATE, AND RETURN THE FORM.

3.

4.

If you answered “Yes” to question 3 on the reverse, complete the information below.
(a) Country of new citizenship

Date acquired (Month-Day-Year)

(b) Current country of residence

Date of change (Month-Day-Year)

If you answered “Yes” to question 4 on the reverse, complete the information below.
(d) Enter date event occurred
(a)

5.

Marriage

(b)

Divorce

(c)

(Month-Day-Year)

Annulment

If you answered “Yes” to question 5 on the reverse, complete the information below.
(a) Check one
Employee

SelfEmployed

(b) Date work began
(Month-Day-Year)

(c) If ended, enter date work stopped
(Month-Day-Year)

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

No

$
$

last year
also give

$

your estimate of earnings for this year

6.

Yes

If you answered “Yes” to question 6 on the reverse, complete the information below.
(a) Date child left

(Month-Day-Year)

(b) Date child returned
(Month-Day-Year)

(c) Name of child

(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 payee (Note: If this form is signed with a mark, a witness must sign below.)

Date

8.

Signature of witness

Date

Form SSA-7162-OCR-SM (5-2009)

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 1631(d)(1), and 1631(e)(1) of the Social Security Act, as amended, authorize us
to collect this information. We will use the information you provide to determine continued
benefit eligibility.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may cause suspension or loss of additional benefits.
We rarely use the information for any purpose other than form making a decision regarding
continuing entitlement to benefits. However, we may use it for the administration and integrity
of our programs. We may also disclose the information to another person or to another agency in
accordance with approved routine uses, including, but not limited to the following:
1.

To enable a third party or an agency to assist us in establishing rights to our
benefits and coverage;

2.

To comply with Federal laws requiring the release of information from our
records (e.g., to the Government Accountability Office and Department of
Veterans Affairs);

3.

To make determinations for eligibility in similar heath and income maintenance
programs at the Federal, State, and local level; and,

4.

To facilitate statistical research, audit, and investigatory activities necessary to
assure the integrity and improvement of our programs (e.g., to the Bureau of the
Census and to private entities under contract with us).

We may also use the information you provide in computer matching programs. Matching
Programs compare our records with records kept by other Federal, State, or local
government agencies. We use the information from these programs to establish or verify
a person’s eligibility for federally funded and administered benefit programs and for
repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act Systems
of Records Notices entitled, Claims Folders Systems, 60-0089, and Electronic Disability
(eDib) Claim Folder, 60-0320. These notices, additional information regarding our
Programs and systems are available on-line at www.socialsecurity.gov or at your Social
Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 (OMB) control number. We estimate that it will take about 5
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 21235-0001.