Form SSA-7161-OCR-SM Report to United States Social Security Administration b

7161
SOCIAL SECURITY ADMINISTRATION

FORM APPROVED
OMB NO. 0960-0049

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.
Telephone number at which you may be
Print your address here only if it is different from the one shown below.
contacted during the day.

1.

2.

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
u
residence in the past 15 months?
Has anyone for whom you receive benefits married, had a divorce
(or annulment) or died in the past 15 months?

u

Has the parent (natural, adoptive or stepparent) or 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.)

u

Did anyone for whom you receive benefits work for someone else or
own a business or farm in the past 15 months?

u

Did any person for whom you receive benefits live apart from you during
any of the past 15 months?

u

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?

u

Were all Social Security benefits received during the past 15 months used for the
beneficiary and/or held for the beneficiary?
u
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

YES

NO

YES

NO

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
u
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.

If you answered "Yes" to question 5 on the other side, complete the information below.
(b) Check which event occurred
(c) Date event occurred
Annulment
Marriage
Death
Divorce

If you answered "Yes" to question 6 on the other side, complete the information below.
(b) Check one
SelfEmployee
Employed

(a) Name of person

(d) If ended, enter date work stopped

Yes

No

(c) Date work began

(e) Lise 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.

(e) Date residence
began

(b) Check which event occurred
(c) Date event occurred
Annulment
Marriage
Death
Divorce

(a) Name of parent

6.

(d) Current country of
residence

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

5.

(c) Date
acquired

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

$
$

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 beneficiary left

(c) Reason for leaving

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

Date

12.

Date

Signature of witness

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