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Form Ssa-7162-Ocr-Sm (03-2004) - Report To United States Social Security Administration Page 2

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 THE QUESTIONS ON

THE OTHER SIDE OF THE FORM, YOU SHOULD GO TO ITEM 7, SIGN, DATE, AND RETURN THE FORM.

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.

(d) Enter date event occurred

(a)

Marriage

(b)

Divorce

(c)

Annulment

If you answered “Yes” to question 5 on the reverse, complete the information below.

(a) Check one

(b) Date work began

(Month-Day-Year)

Employee

Self-

Employed

(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

Yes

! ! ! ! !

Social Security taxes on earnings from this work?

(f) If you answered “yes” to (e) above, enter your total earnings for:

the year before last

! ! ! ! !

and

last year

! ! ! ! !

also give

your estimate of earnings for this year

! ! ! ! !

If you answered “Yes” to question 6 on the reverse, complete the information below.

(a) Date child left

(b) Date child returned (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 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.

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

Date

Firma

Signature of witness

Address (include ZIP code)

Date

Form SSA-7162-OCR-SM (09-2004)

Form Ssa-7162-Ocr-Sm (03-2004) - Report To United States Social Security Administration Page 2

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