Form SSA-7162-INST (01-2021)

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Social Security Administration OMB No. 0960-0049
INSTRUCTIONS FOR COMPLETION OF FORM SSA-7162-OCR-SM
WHAT YOU NEED TO DO
First, please read the instructions below. This is important Item 5. Did you work for someone else or own a business
because not all questions are self-explanatory. Then, or farm since your last report of work to SSA? If not,
complete your report and return it to the Social Security place an “X” in the “NO” box and go on to item 6. If yes,
Administration, P.O. Box 7162, Wilkes-Barre, place an “X” in the “YES” box and turn the form over. In
Pennsylvania, 18767-7162, U.S.A. in the enclosed item 5 on the back, enter in:
envelope within 60 days from the day you receive it. If
you do not return it promptly, we may stop sending
checks to you. (a) a check mark in the first block if you worked for
GENERAL INSTRUCTIONS someone else, or a check mark in the second
block if you were self-employed;
To help us process your report and avoid having to recon-
tact you, please follow these instructions. (b) the month, day and year the work began;
• Use black ink or a dark pencil to complete the report. (c) year the work ended. If not ended, write “not if
the work has ended, enter the month, day and
Please print your answers, except in the signature ended”;
•
block. (d) list each month in the work period indicated in
Place “X’s” in the appropriate “Yes” or “No” boxes on (b) and (c) above that you worked 45 hours or
•
the first page. less. (Explain in “Remarks” why your
• On the first page, keep your “X’s” inside the boxes. employment/self- employment calls for 45 hours
or less);
• You must sign the form on the back page. (e) if the work was done in the U.S. or if U.S. Social
Security taxes (FICA) were paid on earnings
HOW TO FILL OUT THE FORM from this work, check the “Yes,” block. If not,
check the “No” block.
The numbers below match the numbered questions on (f) if the answer in (e) above was “Yes,” enter your
the report. total earnings for the year before last in the first
space, your earnings for last year in the second
Item 1. Do not write in this space if the preprinted space, and give an estimate of this year’s
address in the box is correct. If the preprinted address is earnings in the last space.
incorrect and you have not reported your new address to Item 6. Did you and the child live apart since you last
the Social Security Administration, then print the correct reported the child’s living arrangements to SSA? If not,
address in this space. place an “X” in the “NO” box. If yes, place an “X” in the
Item 2. Enter the telephone number at which you may be “YES” box and turn the form over. In item 6 on the back,
contacted during the day in this space. enter in:
(a) the date the child left;
Item 3. Has there been a change in your citizenship or
your country of residence that you have not yet reported (b) the date the child returned. If the child has not
to SSA? If not, place an “X” in the “NO” box and go on to returned, enter “Not returned”;
item 4. If yes, place an “X” in the “YES” box and turn the (c) the name of the child who did not live with you;
form over. In item 3 on the back, enter in:
(d) the reason for leaving;
(a) the country of new citizenship and the date the
(e) if the child has not returned, the address where
new citizenship was acquired; and/or
the child can be reached.
(b) the current country of residence and the date BE SURE TO TURN THE FORM OVER AND ENTER
the residence began. YOUR SIGNATURE (OR MARK) AND THE DATE IN
ITEM 7. IF YOU SIGN WITH A MARK, A WITNESS
Item 4. since you last reported your marital status to
MUST COMPLETE ITEM 8. IF A WITNESS SIGNS THE
SSA? If not, Have you married or had a divorce or
FORM, HE/SHE SHOULD ENTER HIS/HER NAME,
annulment place an “X” in the “NO” box and go on to item
ADDRESS, AND THE DATE IN ITEM 8.
5. If yes, place an “X” in the “YES” box and turn the form
over. In Item 4 on the back, enter in: ALL KINDS OF WORK SHOULD BE REPORTED

(a), (b) or (c) a check mark next to the event which Every kind of work, trade, apprenticeship or business in
occurred; (d) the date the event occurred. which you engage while you are under age 66 MUST BE
REPORTED. After you notify us of work, we will inform
you if the work has any effect on benefits.