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7162

FORM APPROVED

SOCIAL SECURITY ADMINISTRATION

OMB NO. 0950-0049

REPORT TO 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.

Print your address here only if it is different from the one shown below.

Telephone number at which you may be

contacted during the day.

Telefono:

(+593)

__ __ __ -__ __-__ __ __ __

Claim Number/SSN:

Nombre/Name:

•

(SSN of wage earner)

(SSN del trabajador)

Direccion/Address:

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.

YES

Has there been a change in your citizenship or your country of residence that you have

not yet reported to SSA?

! ! ! ! !

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.

Did you and the child live apart since you last reported the child’s living arrangements

to SSA?

! ! ! ! !

(For SSA Use Only)

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

SSN

PAPERWORK ACT AND PRIVACY ACT NOTICE

The information requested on this form is sought pursuant to the

Explanations about these and other reasons why information you

authority granted in 42 U.S.C. 403(c) 403(g), 405(a) and 405(j). Your

provide us may be used or given out are available in Social Security

response to the questions on this form is required for you to continue

Offices. If you want to learn more about this, contact any Social

to receive benefits. Failure to report those events which can cause

Security office.

suspension of benefits may cause the loss of additional benefits.

Paperwork Reduction Act Statement - This information collection

The information provided will be used to confirm past and continuing

meets the requirements of 44 U.S.C. § 3507, as amended by

entitlement to benefits and may be disclosed by SSA to another

section 2 of the Paperwork Reduction Act of 1995. You do not

governmental agency for the following purposes: (1) to assist SSA in

need to answer these questions unless we display a valid Office

establishing the right of an individual to Social Security coverage and/or

of Management and Budget control number. We estimate that it

benefits; (2) to facilitate statistical research and audit activities

will take about 5 minutes to read the instructions, gather the

necessary to assure the integrity and improvement of the Social

facts, and answer the questions. You may send comments on

Security programs; (3) to comply with Federal laws requiring the

our time estimate above to: SSA, 1338 Annex Building,

exchange of information between SSA and another agency; and (4) to

Baltimore, MD 21235-0001, U.S.A. Send only comments relating to

comply with Freedom of Information Act (5 U.S.C. 552).

our time estimate to this address, not the completed form.

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 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.

Form SSA-7162-OCR-SM (09-2004) Destroy Prior Editions

Continued on the

7162

! ! ! ! !

Reverse

Form Ssa-7162-Ocr-Sm (03-2004) - Report To United States Social Security Administration

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