Form SSA-7163 (01-2021) UF

Discontinue Prior Editions Page 1 of 3

Social Security Administration OMB No. 0960-0050
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

Name of employed or self-employed beneficiary
(If different from worker's)

1. Give the following information about your employment or self-employment outside the United States.

Type of business Work period

Name and address of employer (if self-employed, show (such as e.g. farming, Date ended (MM/DD/YYYY)
"SELF" and address of your trade or business.) doctor, truck driver, Date began
(if not ended, print "NOT
etc.) (MM/DD/YYYY)
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
Month agreement calls for work of 45 hours or less a month, attach a copy of the 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. $
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If you were self-employed during the work period shown in item 1, answer question 4. If not, skip to item 7.

4. (a) While self-employed outside the United States, were you either a legal resident of the United
Yes No
States or a United States citizen? (If "Yes", answer item 4(b). If "No", go on to item 7.)
(b) If you had the option to elect Social Security coverage under a program other than the United Yes No
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 shown Yes No
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 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
statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a
fine or imprisonment.
Signature of Beneficiary Date Signed
7. Signature (First Name, Middle Initial, Last Name) (Write in ink) MM/DD/YYYY

Telephone number(s) at which you may be

Mailing address (number & street, apt. no., P.O. Box, or rural route)
contacted during 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)
Form SSA-7163 (01-2021) UF Page 3 of 3

Privacy Act Statement

Collection and Use of Personal Information

Sections 203 and 205 of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent an accurate and timely decision on any claim filed.

We will use the information to make a determination of eligibility for benefits. We may also share your
information for the following purposes, called routine uses:

1. To the Social Security agency of a foreign country, to carry out the purpose of an international
Social Security agreement entered into between the United States and the other country,
pursuant to section 233 of the Social Security Act.

2. To the Department of State and its agents for administering the Act in foreign countries
through facilities and services of that organization.

In addition, we may share this information in accordance with the Privacy Act and other federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person's eligibility for federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notices (SORNs) 60-0059,
entitled Earnings Recording and Self-Employment Income System, and 60-0089, entitled Claims Folders
Systems. Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.

Paperwork Reduction Act Statement

This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid
Office of Management and Budget (OMB) control number. We estimate that it will take about 12 minutes to
read the instructions, gather the facts, and answer the questions. Send only comments relating to our
time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Explanation of Terms Used in this Questionnaire

1. United States - Include the 50 States, District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, and
American Samoa.

2. Resident - You are a resident of a country if you make your temporary or permanent home there. (Visiting as
a tourist, or on a short business trip, does not establish residence in a country. But going into a country,
setting up permanent quarters there for yourself and your family, and settling down in the community generally
make you a resident of that country even though you intend to return eventually to another country which you
consider to be your permanent home.)