Current SSA-7161-INST

INSTRUCTIONS FOR COMPLETION OF FORM SSA-7161-OCR SM
WHAT YOU NEED TO DO
First please read the instructions below. This is important
because not all questions are self-explanatory. Then,
complete your report and return it to the Social Security
Administration, P.O. Box 7161, Wilkes-Barre, Pennsylvania,
18767-7161, U.S.A. in the enclosed envelope within 60 days
from the day you receive it. If you do not return it promptly,
we may stop sending payments to you.
GENERAL INSTRUCTIONS
To help us process your report and avoid having to
recontact you, please follow these instructions.
•Use black ink or a dark pencil to complete the report.
•Please print your answers, except in the signature block.
•Place "X's" in the appropriate "Yes" or "No" boxes on
the first page.
•On the first page, keep your "X's" inside the boxes.
•You must sign the form on the back page.

(Note that it is not necessary that the parent have been
receiving benefits.) If not, place an "X" in the "NO" box and
go on to item 6. If yes, place an "X" in the "YES" box and
turn the form over. In item 5 on the back, enter in:
(a) the name of the parent;
(b) a check mark next to which even occurred;
(c) the date the event occurred.
Item 6. Did anyone for whom you receive benefits work for
someone else or own a business or farm in the past 15
months? If not, place an "X" in the "NO" box and go on to
Item 7. If yes, place an "X" in the "YES" box and turn the
form over. In item 6 on the back, enter in:
(a) the name of the person who worked or owned a
business or farm;
(b) a check mark in the first block if he/she worked for
someone else or a check mark in the second block if
he/she was self-employed;

HOW TO FILL OUT THE FORM

(c) the month, day, and year the work began;

The numbers below match the numbered questions on the report.

(d) if the work has ended, enter the month, day, and year
the work ended. If not ended, write "Not Ended";

Item 1. Do not write in this space if the preprinted address in the
box is correct. If the preprinted address is incorrect and you have
not reported your new address to the Social Security
Administration, then print the correct address in this space.
Item 2. Enter the telephone number at which you may be
contacted during the day in this space.
Item 3. Has anyone for whom you receive benefits changed his/
her citizenship or country of residence in the past 15 months? If
not, place an "X" in the "NO" box and go on to item 4. If yes, place
an "X" in the "YES" box and turn the form over. In item 3 on the
back, enter in:

(a) the name of the person;
(b) the country of new citizenship;
(c) the date the new citizenship was acquired; and/or
(d) the current country of residence;
(e) the date residence began.
Item 4. Has anyone for whom you receive benefits married,
had a divorce (or annulment) or died in the past 15 months?
If not, place an "X" in the "NO" box and go on to item 5. If
yes, place an "X" in the"YES" box and turn the form over. In
item 4 on the back, enter in:
(a) the name of the person;
(b) a check mark next to which even occurred;
(c) the date the event occurred.
Item 5. 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?

Form SSA-7161-INST (04-2011) Destroy Prior Editions

(e) list each month in the work period indicated in (c) and
(d) above that he/she worked 45 hours or less. (Explain
in "Remarks" why his/her employment/selfemployment calls for 45 hours or less);
(f) if the work was done in the U.S. or if U.S. Social
Security taxes (FICA) were paid on earnings from this
work, check the "Yes" black. If not, check the "No"
block;
(g) if the answer in (f) above was "Yes" enter his/her total
earnings for the last year in the first space and give an
estimate of this year's earnings in the next space.
Item 7. Did any person for whom you receive benefits live
apart from you during any of the past 15 months? If not,
place an "X" in the "NO" box and go on to item 8. If yes,
place an "X" in the "YES" box and turn the form over. In
item 7 on the back, enter in:
(a) the name of the person who did not live with you;
(b) the date he/she left;
(c) the reason for leaving
(d) the date he/she returned. If he/she has not
returned, enter "Not returned";
(e) the address where he/she can be reached.
Item 8. Did you give the Social Security check or the full
amount of the benefits to another person (for example, the
beneficiary's custodian or the beneficiary himself) during
the past 15 months? If not, place an "X" in the "NO" box
and go on to item 9. If yes, place an "X" in the "YES" box
and turn the form over. In item 8 on the back, show to
whom the funds were given (the custodian, the beneficiary,
etc.).

Item 9. Were all of the Social Security benefits received
during the past 15 months used for the beneficiary and/or
held for the beneficiary? If all the benefits were used or, if
all were not used, but the remainder were held for the
beneficiary, place an "X" in the "YES" box and go on to
item 10. If not, place an "X" in the "NO" box, turn the form
over and explain in "Remarks" what was done with the
benefits.
Item 10. A. Show the manner in which any amounts not
used for the beneficiary are being held. If the benefits are
not in a bank account, check "Other" and explain in
"Remarks" on the back. B. Show the title or ownership of
the account in which the amounts are held.
BE SURE TO TURN THE FORM OVER AND ENTER
YOUR SIGNATURE (OR MARK) AND THE DATE IN ITEM
11. IF YOU SIGN WITH A MARK, A WITNESS MUST
COMPLETE ITEM 12. IF A WITNESS SIGNS THE FORM,
HE/SHE SHOULD ENTER HIS/HER NAME, ADDRESS,
AND THE DATE IN ITEM 12.
ALL KINDS OF WORK SHOULD BE REPORTED
Every kind of work, trade, apprenticeship or business in
which the beneficiary engages while the beneficiary is
under age 66 MUST BE REPORTED. After you notify us of
work, we will inform you if the work has any effect on
benefits.
YOUR RESPONSIBILITY AS A REPRESENTATIVE
PAYEE
Your job is to use the Social Security benefits you receive
for the personal care and well-being of the beneficiary. This
is true whether you are a relative, friend, court-appointed
guardian, or official of a private agency or institution. You
must keep yourself informed of the beneficiary's needs so
you can decide how the benefits should be used. You must
account for the use of the benefits on the form enclosed.
This accounting will be reviewed by the Social Security
Administration and is subject to verification. Therefore, you
should keep a record of the amount of benefits you
received and how you used them (keep receipts, cancelled
checks, etc.).
You must notify the Social Security Administration when
the beneficiary changes residence or you are no longer
responsible for the care and welfare of the beneficiary. You
must also report to us promptly if the beneficiary dies,
marries, is adopted, goes to work, or enters or leaves a
hospital or institution.

Form SSA-7161-INST (04-2011) Destroy Prior Editions

PRIVACY ACT STATEMENT- Collection and Use of
Personal Information-- The 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 Social Security benefits on this claim. Your
response is voluntary. However, failure to provide the
requested information may prevent us from making an
accurate and timely decision, or could result in the loss of
benefits.
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 § 552a(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 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
contained in our System of Records Notice 60-0089 (Claims
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 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 15
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, U.S.A. Send only comments relating to
our time estimate to this address, not the completed
form.