Form Ssa-7163a-F4 - Supplemental Statement Regarding Farming Activities Of Person Living Outside The Usa

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. SOCIAL SECURITY ADMINISTRATION
Form Approved
TOE 220
OMB No. 0960-0103
SUPPLEMENTAL STATEMENT REGARDING FARMING ACTIVITIES
OF PERSON LIVING OUTSIDE THE U.S.A.
(This statement is to be completed by a beneficiary living on a farm or operating a
farm outside the United States.) (See Page 4 for Privacy Act/Paperwork Act Notice.)
NAME OF BENEFICIARY
SOCIAL SECURITY CLAIM NUMBER
1a. GIVE THE DATE YOUR FARM RESIDENCE
1b. GIVE THE DATE IT ENDED
1c. HOW DID IT END? (Sale, lease of land, etc.)
OR OPERATION BEGAN OUTSIDE THE U.S.
2a. DO YOU OWN THE FARM?
2b. GIVE NAME OF THE OWNER AND INDICATE HIS RELATIONSHIP TO YOU
YES
NO
(If "Yes," go on to question 3)
2c. EXPLAIN THE TYPE OF AGREEMENT OR CONTRACT YOU HAVE WITH THE OWNER
2d. HOW ARE YOU PAID? (Check one)
WEEKLY
MONTHLY
OTHER (Specify)
DAILY
3. WHAT PHYSICAL OR MANAGEMENT SERVICES DO YOU PERFORM IN CONNECTION WITH THE FARM?
4a. WHAT IS THE LAND AREA OF THE
4b. HOW MUCH OF THIS LAND IS USED FOR
FARM?
(1) GROWING CROPS
(2) GRAZING ANIMALS
(3) ORCHARDS (Olive, fig, or
(4) OTHER
other food-bearing trees or
(Explain)
vines)
Answer Questions 5 through 12 if you own or operate the farm. Be sure to sign this statement.
5. Give below the types and quantity of livestock, poultry, crops, and produce RAISED on the farm in the present year
and last year.
PRESENT YEAR
LAST YEAR
a.
TYPES OF LIVESTOCK AND POULTRY
NO. OF HEAD
TYPES OF LIVESTOCK AND POULTRY
NO. OF HEAD
b.
TYPES OF CROPS
LAND AREA USED
YIELD
TYPES OF CROPS
LAND AREA USED
YIELD
6. Give below the following information about the livestock, poultry, crops, and produce SOLD.
PRESENT YEAR
LAST YEAR
ITEMS
QUANTITY
AMT. RECEIVED
ITEMS
QUANTITY
AMT. RECEIVED
(local currency)
(local currency)
Form SSA-7163A-F4 (08-2011) EF (08-2011)
PAGE 1
(over)
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