Form SSA-7161-OCR-SM (01-2021) Discontinue Prior Editions Page 1 of 2 Social Security Administration OMB No, 0960-0049 REPORT TO THE UNITED STATES SOCIAL SECURITY ADMINISTRATION BY PERSON RECEIVING BENEFITS FOR A CHILD OR FOR AN ADULT UNABLE TO HANDLE FUNDS IMPORTANT: FAILURE TO COMPLETE AND RETURN THIS FORM WITHIN 60 DAYS WILL RESULT IN A SUSPENSION OF BENEFITS, SIGN AND RETURN THIS FORM IN THE ENCLOSED ENVELOPE. SEE INSTRUCTIONS ENCLOSED. Print your address here only iit is different from the one shown below. |2. Telephone number at which you may be contacted during the day. Name: Social Security Number / Claim Number: Current Address: IF YOU ANSWER “YES" TO ANY OF THE QUESTIONS 3 THROUGH 8 BELOW, PLEASE TURN THIS FORM OVER AND CONTINUE ON THE BACK. YOU MUST SIGN YOUR NAME IN ITEM 14 ON THE BACK OF THIS FORM ] yes | NO. 3, |Has anyone for whom you receive benefits changed his/her citizenship or country of residence in the past 15 months? 4, | Has anyone for whom you receive benefits married, had a divorce (or annulment) or died in the past 15 months? 5. | Has the parent (natural, adoptive or stepparent) or any child for whom you receive benefits died, married or had a divorce (or annulment) in the past 15 months? (It is not necessary that the parent have been receiving benefits.) 6. | Did anyone for whom you receive benefits work for someone else or own a business or farm in the past 15 months? 7. | Did any person for whom you receive benefits live apart from you during any of the past 15 months? 8. | Did you give the Social Security checks or the full amount of the benefits to another person (for example, the beneficiary's custodian or the beneficiary himself/herself) during the past 15 months? 9. | Were all Social Security benefits received during the past 15 months used for the beneficiary and/or held for the beneficiary? Yes | NO If "No" explain in "Remarks" on the back of this form what was done with the benefits 70| A. Show the manner in which any amounts not used for the B. Show the Tile or Ownership of the Account beneficiary are being held: Bank It*Other’, explain in "Remarks"on TF account [1 ther the back of this form. OTHER REPORTABLE EVENTS. (FOR SSA USE ONLY) In addition to the events listed on this form, you are responsible for reporting any other event that may affect benefit payments, $SN Continued on the reverseForm SSA-7161-OCR-SM (01-2021) Page 2 of 2 TF YOU ANSWERED "VES" TO ANY OF THE QUESTIONS 3 THROUGH 8 ON THE OTHER SIDE OF THIS FORM, YOU MUST COMPLETE THE CORRESPONDING BLOCK(S) BELOW. IF YOU ANSWERED "NO" TO ALL OF THE QUESTIONS 3 THROUGH 8 ON THE OTHER SIDE OF THE FORM, YOU SHOULD GO TO ITEM 11, SIGN, DATE AND RETURN THE FORM. 3]If you answered "Yes" to question 3 on the other side, complete the information below. (a) Name of person (b) Country of new (c) Date (¢) Current country of ]{e) Date residence citizenship acquired residence began “4]If you answered "Yes" to question 4 on the other side, complete the information below. (a) Name of person (@) Check which event occurred (@) Date event acourred (Marriage =] Annulment C1 Divorce C2 Death 5|If you answered "Ves" fo question 5 on the other side, complete the information below. (@) Name of parent (@) Check which event occurred (Date event occurred ( Marriage =] Annulment C1 Divorce Death 6] Ifyou answered "Yes" fo question 6 on the other side, complete the information below. (a) Name of person (©) Check one (©) Date work began (Employee) Self-Employed (a) ended, enter date work stopped _|(e) List each month that he/she worked 45 hours or less (Explain in Remarks) [() Was this work done in the United Slates or did_| (g) Ifyou answered "Yes to (f), enter hisiher helshe pay United States Social Security taxes total earnings for last year $ on earings from this work [AND give your estimate of this Yes No year's earnings. $ 7| If you answered "Yes" to question 7 on the other side, complete the information below. [(@) Name of beneficiary who did not live | (b) Date beneficiary | () Reason for leaving (@ Date beneficiary with you left returned {(@) Ifyou listed someone in (a) above who has not returned, enter the address where he/she can be reached. (Indude ZIP code) If you answered "Yes" to question 8 on the other side, show to whom the funds were given. REMARKS, IMPORTANT: | declare under penally of perjury that [have examined all of the information on this form, and on any accompanying statements or forms, and itis true and correct to the best of my knowledge. | understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both. 11] Signature or mark of beneficiary (Note: If this form is signed with a mark, a witness must sign below) | Date 12| Signature of witness Date