Form Ssa-7163a-F4 - Supplemental Statement Regarding Farming Activities Of Person Living Outside The Usa Page 3

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11a. Give the name and relationship to you (if any) of each person working on the farm.
NAME
RELATIONSHIP
DESCRIBE DUTIES PERFORMED
b. HOW ARE THEY PAID? (Check appropriate box or boxes)
ROOM AND
OTHER
CROP OR
CASH WAGE
BOARD
(Specify)
LIVESTOCK SHARE
12.List expenses (in local currency) for the present year and last year.
(Do not include material supplied by Government agencies.)
YEAR
TYPE OF EXPENSE
COST
TYPE OF EXPENSE
COST
1. Present
Labor hired
1.
Electricity, gasoline and
1.
other fuel
2. Last
2.
2.
1. Present
Feed, seeds and
Livestock and poultry
1.
1.
fertilizer purchased
purchased
2. Last
2.
2.
1. Present
Veterinary fees
1.
Taxes and interest on
1.
farm notes
2. Last
2.
2.
1. Present
Machine hire
Other expenses
1.
1.
(Specify below)
2. Last
2.
2.
1. Present
Farm supplies and cost
1.
1.
of repairs
2. Last
2.
2.
REMARKS: (This space may be used for any additional information you may wish to give)
Knowing that anyone making a false statement or representation of a material fact in application or for use in determining
a right to payment under the Social Security Act commits a crime punishable under Federal law, I certify that the above
statements are true.
SIGNATURE OF PERSON COMPLETING THIS STATEMENT
If this statement has been signed by mark (x), or fingerprint, two
(First name, middle initial, last name) (Write in ink)
witnesses who know the signer must sign below, giving their full
addresses.
SIGN
u
1. SIGNATURE OF WITNESS
HERE
ADDRESS OF WITNESS (Street number, city and country)
STREET ADDRESS
CITY, COUNTRY, POSTAL CODE
2. SIGNATURE OF WITNESS
ADDRESS OF WITNESS (Street number, city and country)
DATE (Month, day and year)
Form SSA-7163A-F4 (08-2011) EF (08-2011)
PAGE 3

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