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Get SSA-7163 2021-2023

Form SSA-7163 03-2014 EF 03-2014 Destroy Prior Editions Page 1 If you need more space use the REMARKS section on Page 2. Form 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 NAME OF EMPLOYED OR SELF-EMPLOYED BENEFICIARY BENEFICIARY S SOCIAL SECURITY NUMBER If different from worker s 1. Give the following information about your employment or self-employment outside the United States. NAME AND ADDRESS OF EMPLOYER IF SELF-EMPLOYED SHOW SELF AND ADDRESS OF YOUR TRADE OR BUSINESS* TYPE OF BUSINESS Work Period DATE BEGAN Month Day Year DATE ENDED Month Day Year IF NOT ENDED PRINT NOT 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 MONTH 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 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 Yes No United States FICA taxes 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. 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. b If you had the option to elect Social Security coverage under a program other than the 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 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* 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.

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