Questionnaire About Employment Or Self-Employment Outside The United States Page 2

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4. (a) While self-employed outside the United States, were you either a legal resident of the
United States or a United States citizen? (If "Yes", answer item 4(b). If "No", go on to item 7.)
Yes
No
(b) If you had the option to elect Social Security coverage under a program other than the
Yes
No
United States Social Security program, did you elect such coverage?
(If "No," answer items 5 and 6. If "Yes," list the country under whose program you elected
coverage and go on to item 7.)
(country)
5. Did you file income tax returns with the United States Internal Revenue Service for all years
Yes
No
shown in item 1?
(If "Yes", attach a copy of Schedule C (or F) and SE and Form 2555 of your United States Income Tax Return filed for
each year of the work period shown in item 1. If your earnings derived from a partnership, attach a copy of Form 1065.)
If you answer "No" to question 5, furnish a breakdown of your gross receipts, business expenses, and net earnings for
each year shown in item 1 and explain your reason for not filling in REMARKS.
YEAR
GROSS EARNINGS
BUSINESS EXPENSES
NET EARNINGS
$
$
$
$
$
$
$
$
$
6. If you are now self-employed, show how much you expect your net earnings to be for the current year.
$
REMARKS: (This space may be used for explaining any answers to the questions. If you need more space, attach a
separate sheet.)
ALWAYS COMPLETE THIS PORTION
I know that anyone who makes or causes to be made a false statement or representation of material fact in an application
or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law
by fine, imprisonment or both. I affirm that all information I have given in this document is true.
SIGNATURE OF BENEFICIARY
DATE SIGNED
7. SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
(MONTH, DAY, YEAR)
MAILING ADDRESS (NUMBER & STREET, APT. NO., P.O. BOX, OR RURAL
TELEPHONE NUMBER(S) AT WHICH
YOU MAY BE CONTACTED DURING
ROUTE)
THE DAY (Include Area Code)
CITY
POSTAL CODE
ENTER NAME OF COUNTRY IN WHICH YOU NOW LIVE.
Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the claimant must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (No. and street, city, country and postal code)
ADDRESS (No. and street, city, country and postal code)
Page 2
Form SSA-7163 (03-2014) EF (03-2014)

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