SSA-7163A-F4 - Current

Form SSA-7163A (12-2023) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 6
OMB No. 0960-0103

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 6 for Privacy Act/Paperwork Act Notice.)
Name of Beneficiary

Social Security Claim Number

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
Weekly
Monthly

Other (Specify)

3. 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
(2) Grazing
(3) Orchards (Olive, fig, (4) Other
crops
animals
or other food-bearing
(Explain)
trees or vines.)

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

Last Year
No. of Head

Types of Livestock and Poultry

No. of Head

Form SSA-7163A (12-2023) UF

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Present Year
Land area
b. Types of crops
used

Yield

Types of crops

Last Year
Land area
used

Yield

6. Give below the following information about the livestock, poultry, crops, and produce SOLD.
Present Year
Items

Quantity

Last Year
Amount
Received
(local currency)

Items

Quantity

Amount
Received
(local currency)

7. Give below the following information about livestock, poultry, crops or produce which the family used
or bartered.
Present Year
Item

Amount Used
on Farm

Amount Bartered

Last Year

Amount and Kind of Goods and/or
Services Received in Exchange for
Bartered Goods

Form SSA-7163A (12-2023) UF

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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

Last Year
Amount Received
(local currency)

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.)

Form SSA-7163A (12-2023) UF

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

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
Labor hired
2. Last

1.
2.

Electricity, gasoline and
other fuel

1.
2.

1. Present Feeds, seeds and
2. Last
fertilizer purchased

1.
2.

Livestock and poultry
purchased

1.
2.

1. Present
Veterinary fees
2. Last

1.
2.

Taxes and interest on
farm notes

1.
2.

1. Present
Machine hire
2. Last

1.
2.

Other expenses
(Specify below)

1.
2.

1. Present Farm supplies and cost
2. Last
of repairs

1.
2.

1.
2.

Form SSA-7163A (12-2023) UF

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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.
SIGNATURE OF PERSON COMPLETING THIS STATEMENT
(First name, middle initial, last name) (Write in ink)

Date (Month, day and year)

SIGN HERE
Street Address

City, Country, Postal Code

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

2. Signature of Witness

Address of Witness (Street number, city and country) Address of Witness (Street number, city and country)

Form SSA-7163A (12-2023) UF

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Privacy Act Statement
Collection and Use of Personal Information
Section 203 of the Social Security Act, as amended, allows us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may prevent an accurate
and timely decision on any claim filed and may result in the loss of benefits.
We will use the information you provide to determine continuing eligibility for benefits and whether such
benefits are subject to deductions. We may also share your information for the following purposes, called
routine uses:
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social
Security Administration (SSA) in the efficient administration of its programs. We will disclose
information under the routine use only in situations in which we may enter into a contractual or
similar agreement with a third party to assist in accomplishing an SSA function relating to this
system of records; and
• To student volunteers, individuals working under a personal services contract, and other workers
who technically do not have the status of Federal employees, when they are performing work for
SSA, as authorized by law, and they need access to personally identifiable information in SSA
records in order to perform their assigned agency functions.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person's eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0090,
entitled Master Beneficiary Record, as published in the Federal Register (FR) on January 11, 2006, at 71 FR
1826. Additional information, and a full listing of all our SORNs, is available on our website at
www.ssa.gov/privacy.

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 60 minutes to read the instructions, gather the facts, and answer the
questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
You can find your local Social Security office through SSA’s website at www.socialsecurity.gov.
Offices are also listed under U. S. Government agencies in your telephone directory or you may call
Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments regarding this burden
estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate or other
aspects of this collection to this address, not the completed form.