Questionnaire About Employment Or Self-Employment Outside The United States
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1
2
3Form Approved
OMB No. 0960-0050
TOE 220
SOCIAL SECURITY ADMINISTRATION
QUESTIONNAIRE ABOUT EMPLOYMENT OR
SELF-EMPLOYMENT OUTSIDE THE UNITED STATES
(See Page 3 for Privacy Act Statement)
PLEASE PRINT YOUR ANSWERS
NAME OF WORKER ON WHOSE ACCOUNT BENEFITS ARE BEING PAID
WORKER'S SOCIAL SECURITY CLAIM NUMBER
BENEFICIARY'S SOCIAL SECURITY NUMBER (If
NAME OF EMPLOYED OR SELF-EMPLOYED BENEFICIARY
different from worker's)
1. Give the following information about your employment or self-employment outside the United States.
Work Period
NAME AND ADDRESS OF EMPLOYER (IF
TYPE OF BUSINESS
SELF-EMPLOYED, SHOW "SELF"AND ADDRESS
DATE BEGAN
DATE ENDED (Month, Day, Year)
OF YOUR TRADE OR BUSINESS.)
(IF NOT ENDED, PRINT "NOT
(Month, Day, Year)
ENDED".)
2. List any month(s) of the work period(s) shown in item 1 in which you worked 45 hours or less and explain fully:
EXPLANATION OF WHY YOU WERE EMPLOYED OR SELF-EMPLOYED 45 HOURS OR LESS IN MONTH(S)
LISTED. (If your employment agreement calls for work of 45 hours or less a month, attach a copy of the
MONTH
agreement or a written statement from your employer explaining the terms of the agreement)
IF YOU WORKED AS AN EMPLOYEE FOR WAGES DURING A WORK PERIOD SHOWN IN ITEM 1, ANSWER
QUESTION 3. IF NOT, SKIP TO ITEM 4.
3. (a) Was the employment covered under the United States Social Security program; i.e., were the wages subject to
United States FICA taxes?
Yes
No
(If "No," go on to item 4.)
(If "Yes," enter the total amount of wages earned during each year of the work period.)
YEAR
TOTAL WAGES (AS SHOWN ON U.S. FORM W-2 BEFORE PAYROLL DEDUCTIONS)
$
$
$
(b) If you are now employed, please submit an estimate of the gross wages (before payroll deductions) you expect to
$
earn this year.
IF YOU WERE SELF-EMPLOYED DURING THE WORK PERIOD SHOWN IN ITEM 1, ANSWER QUESTION 4. If not,
skip to item 7.
(If you need more space use the REMARKS section on Page 2.)
Form SSA-7163 (03-2014) EF (03-2014)
Page 1
Destroy Prior Editions
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