Form Ssa-7161-Ocr-Sm - Report To United States Social Security Administration Page 2

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IF YOU HAVE ANSWERED “YES” TO ANY OF QUESTIONS 3 THROUGH 8 ON THE OTHER SIDE OF THIS FORM, YOU
MUST COMPLETE THE CORRESPONDING BLOCK(S) BELOW. IF YOU ANSWERED “NO” TO ALL OF THE QUESTIONS 3
THROUGH 8 ON THE OTHER SIDE OF THE FORM, YOU SHOULD GO TO ITEM 11, SIGN, DATE, AND RETURN THE FORM.
3.
If you answered “Yes” to question 3 on the other side, complete the information below.
(b) Country of new
(c) Date
(d) Current country
(e) Date residence
(a) Name of person
citizenship
acquired
of residence
began
4.
If you answered “Yes” to question 4 on the other side, complete the information below.
(b) Check which event occurred
(c) Date event
(a) Name of person
occurred
Marriage
Annulment
Divorce
Death
If you answered “Yes” to question 5 on the other side, complete the information below.
5.
(b) Check which event occurred
(c) Date event
(a) Name of parent
occurred
Death
Marriage
Divorce
Annulment
6.
If you answered “Yes” to question 6 on the other side, complete the information below.
(b) Check one
(c) Date work
(a) Name of person
began
Employee
Self-
Employed
(d) If ended, enter date work stopped
(e) List each month that he/she worked 45 hours or less (Explain in Remarks)
(f) Was this work done in the United States or
(g) If you answered “yes” to (f), enter his/her
did he/she pay United States Social
total earnings for last year
®
$
Security taxes on earnings from this work?
AND give your estimate of this
year’s earnings.
®
$
Yes
No
7.
If you answered “Yes” to question 7 on the other side, complete the information below.
(a) Name of beneficiary who did not live
(a) Name of beneficiary who did not live
(b) Date bene-
(c) Reason for leaving
(d) Date beneficiary
with you
with you
ficiary left
returned
(e) If you listed someone in (a) above who has not returned, enter the address where he/she can be reached.
(Include ZIP code)
If you answered “Yes” to question 8 on the other side, show to whom the funds were given.
8.
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 payee (Note: If this form is signed with a mark, a witness must sign below.)
Date
11.
Firma del Representante
Signature of witness
Address (include ZIP code)
Date
12.
Form SSA-7161-OCR-SM (03-2004)

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