SOCIAL SECURITY ADMINISTRATION
OMB NO. 0960-0049
REPORT TO UNITED STATES SOCIAL SECURITY ADMINISTRATION
BY PERSON RECEIVING BENEFITS FOR A CHILD OR FOR AN ADULT UNABLE TO HANDLE FUNDS
IMPORTANT: FAILURE TO COMPLETE AND RETURN THIS FORM WITHIN 60 DAYS WILL RESULT IN A
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.
__ __ __ -__ __-__ __ __ __
(SSN of wage earner)
(SSN del trabajador)
IF YOU ANSWER “YES” TO ANY OF THE QUESTIONS 3 THROUGH 8 BELOW, PLEASE TURN THIS FORM OVER
AND CONTINUE ON THE BACK. YOU MUST SIGN YOUR NAME IN ITEM 11 ON THE BACK OF THIS FORM
Has anyone for whom you receive benefits changed his/her citizenship or country
of residence in the past 15 months?
Has anyone for whom you receive benefits married, had a divorce
(or annulment) or died in the past 15 months?
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? (It is not necessary that the parent have been receiving benefits.)
Did anyone for whom you receive benefits work for someone else or own a
business or farm in the past 15 months?
Did any person for whom you receive benefits live apart from you during
any of the past 15 months?
Did you give the Social Security checks 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?
Were all Social Security benefits received during the past 15 months used for the
beneficiary and/or held for the beneficiary?
If “No”, explain in “Remarks” on the back of this form what was done with the benefits.
Show the manner in which any amounts not
Show the Title or Ownership of the Account:
Nombre(s) en la cuenta bancaria
used for the beneficiary are being held:
If “Other”, explain in
“Remarks” on the
back of this form.
(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.
Continued on the
Form SSA-7161-OCR-SM (03-2004) Destroy Prior Editions