Form SSA-7162-OCR-SM Report to United States Social Security Administration

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
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not yet reported to SSA?

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

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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?

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YES

NO

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
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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.
Privacy Act Statement/Collection and Use of Personal
InformationThe United States Code of Federal regulations (42 U.S.C § 403(c),
403(g), 405(a) and 405(j)) authorize us to collect the information on
this form. The information you provide will be used to determine if we
can continue to pay you Social Security benefits. Your response is
voluntary. However, failure to provide the requested information may
prevent us from making an accurate and timely decision on your
claim, or could result in the loss of benefits.

See Revised Privacy Act Statement Attached

We rarely use the information provided on this form for any purpose
other than for determining the continued entitlement to benefit
payments. However, in accordance with 5 U.S.C. § 522a(b) of the
Privacy Act, we may disclose the information provided on this form
(1) to enable a third party or an agency to assist Social Security in
establishing rights to Social Security benefits and/or coverage; (2) to
make determinations for eligibility in similar health and income
maintenance programs at the Federal, State and local level; (3) to
comply with Federal laws requiring the disclosure of the information
from our records; and (4) to facilitate statistical research, audit or
investigative activities necessary to assure the integrity of SSA
programs.
We may also use the information you provide when we match
records by computer. Computer matching programs compare our

Form SSA-7162-OCR-SM (7-2011) Destroy Prior Editions

(For SSA Use Only)
SSN
records with those of other Federal, State, or local government
agencies. Information from these matching programs can be used to
establish or verify a person's eligibility for Federally-funded or
administered benefit programs and for repayment of payments or
delinquent debts under these programs.
A complete list of routine uses for this information is contrained in
our System of Records Notice 60-0069 (Claimes Folders System).
Additional information regarding this form and our other system of
records notices and Social Security programs are available from our
Internet website at www.socialsecurity.gov or at any U.S. Embassy,
consulate, VARO or U.S. Social Security office.
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 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 5401 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
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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.
Marriage

(a)

5.

(b)

Divorce

(c)

Annulment

(d) Enter date event occurred
(Month-Day-Year)

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:

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the year before last
and
last year
also give
your estimate of earnings for this year

6.

Yes

No

$

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$

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$

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 beneficiary (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 (7-2011)