Form Ssa-7161-Ocr-Sm - Report To United States Social Security Administration printable pdf download

Form Ssa-7161-Ocr-Sm - Report To United States Social Security Administration

7161

FORM APPROVED

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.

Telefono:

(+593)

Nombres/Names:

Claim Number/SSN:

__ __ __ -__ __-__ __ __ __

•

(SSN of wage earner)

(SSN del trabajador)

Direccion/Address:

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

YES

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?

YES

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.

10.

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:

Bank

Other

If “Other”, explain in

Account

“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.

SSN

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Form SSA-7161-OCR-SM (03-2004) Destroy Prior Editions

7161

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Form Ssa-7161-Ocr-Sm - Report To United States Social Security Administration

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