Form SSA-7163A-F4 Supplemental Statement Regarding Farming Activities of P

. SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0103

TOE 220

SUPPLEMENTAL STATEMENT REGARDING FARMING ACTIVITIES
OF PERSON LIVING OUTSIDE THE U.S.A.
(This statement is to be completed by a beneficiary living on a farm or operating a
farm outside the United States.) (See Page 4 for Privacy Act/Paperwork Act Notice.)
NAME OF BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

1a. GIVE THE DATE YOUR FARM RESIDENCE
OR OPERATION BEGAN OUTSIDE THE U.S.

2a. DO YOU OWN THE FARM?

YES

1b. GIVE THE DATE IT ENDED

1c. HOW DID IT END? (Sale, lease of land, etc.)

2b. GIVE NAME OF THE OWNER AND INDICATE HIS RELATIONSHIP TO YOU

NO

(If "Yes," go on to question 3)
2c. EXPLAIN THE TYPE OF AGREEMENT OR CONTRACT YOU HAVE WITH THE OWNER
2d. HOW ARE YOU PAID? (Check one)

DAILY

WEEKLY

OTHER (Specify)

MONTHLY

3. WHAT PHYSICAL OR MANAGEMENT SERVICES DO YOU PERFORM IN CONNECTION WITH THE FARM?

4a. WHAT IS THE LAND AREA OF THE
FARM?

4b. HOW MUCH OF THIS LAND IS USED FOR
(1) GROWING CROPS

(2) GRAZING ANIMALS

(3) ORCHARDS (Olive, fig, or
other food-bearing trees or
vines)

(4) OTHER
(Explain)

Answer Questions 5 through 12 if you own or operate the farm. Be sure to sign this statement.
5. Give below the types and quantity of livestock, poultry, crops, and produce RAISED on the farm in the present year
and last year.
LAST YEAR

PRESENT YEAR
a.

TYPES OF LIVESTOCK AND POULTRY

b.

TYPES OF CROPS

LAND AREA USED

NO. OF HEAD

YIELD

TYPES OF LIVESTOCK AND POULTRY

TYPES OF CROPS

LAND AREA USED

NO. OF HEAD

YIELD

6. Give below the following information about the livestock, poultry, crops, and produce SOLD.
PRESENT YEAR
ITEMS

QUANTITY

Form SSA-7163A-F4 (08-2011) EF (08-2011)
Destroy Prior Editions

LAST YEAR
ITEMS

AMT. RECEIVED
(local currency)

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QUANTITY

AMT. RECEIVED
(local currency)

(over)

7. Give below the following information about livestock, poultry, crops or produce which the family used or
bartered.
PRESENT YEAR
ITEM

AMT. USED
ON FARM

AMOUNT
BARTERED

LAST YEAR
AMT. AND KIND OF GOODS
AND/OR SERVICES
RECEIVED IN EXCHANGE FOR
BARTERED GOODS

ITEM

AMT. USED
ON FARM

AMOUNT
BARTERED

AMT. AND KIND OF GOODS
AND/OR SERVICES
RECEIVED IN EXCHANGE FOR
BARTERED GOODS

8. Give below the following information about other income or payments received from your farming operation (such as
government agricultural program payments, patronage dividends, breeding fees, etc.)
PRESENT YEAR
TYPE OF INCOME

LAST YEAR
AMOUNT RECEIVED
(local currency)

TYPE OF INCOME

AMOUNT RECEIVED
(local currency)

9. Give description and age of farm equipment or machinery you have (such as tractor, wagon, truck, etc.) (If none, show
none.)

10.What animals do you have to work the farm? (If none, show none.)

Form SSA-7163A-F4 (08-2011) EF (08-2011)

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11a. Give the name and relationship to you (if any) of each person working on the farm.
NAME

RELATIONSHIP

DESCRIBE DUTIES PERFORMED

b. HOW ARE THEY PAID? (Check appropriate box or boxes)

CROP OR
LIVESTOCK SHARE

CASH WAGE

ROOM AND
BOARD

OTHER
(Specify)

12.List expenses (in local currency) for the present year and last year.
(Do not include material supplied by Government agencies.)
YEAR

TYPE OF EXPENSE

COST

TYPE OF EXPENSE

COST

1. Present
2. Last

Labor hired

1.
2.

Electricity, gasoline and
other fuel

1.
2.

1. Present
2. Last

Feed, seeds and
fertilizer purchased

1.
2.

Livestock and poultry
purchased

1.
2.

1. Present
2. Last

Veterinary fees

1.
2.

Taxes and interest on
farm notes

1.
2.

1. Present
2. Last

Machine hire

1.
2.

Other expenses
(Specify below)

1.
2.

1. Present
2. Last

Farm supplies and cost
of repairs

1.
2.

1.
2.

REMARKS: (This space may be used for any additional information you may wish to give)

Knowing that anyone making a false statement or representation of a material fact in application or for use in determining
a right to payment under the Social Security Act commits a crime punishable under Federal law, I certify that the above
statements are true.
If this statement has been signed by mark (x), or fingerprint, two
witnesses who know the signer must sign below, giving their full
addresses.

SIGNATURE OF PERSON COMPLETING THIS STATEMENT
(First name, middle initial, last name) (Write in ink)

1. SIGNATURE OF WITNESS

SIGN
HERE

ADDRESS OF WITNESS (Street number, city and country)

2. SIGNATURE OF WITNESS
ADDRESS OF WITNESS (Street number, city and country)

Form SSA-7163A-F4 (08-2011) EF (08-2011)

u

STREET ADDRESS

CITY, COUNTRY, POSTAL CODE
DATE (Month, day and year)

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Privacy Act Statement
See Revised
Collection and Use of Personal Information
Privacy Act
Statement
Sections 403(b), 403(c), and 405(a) of the Social Security Act, as amended,
authorize us to collect this
information. The information you provide will be used to confirm past and continuing entitlement to benefits
and to determine whether such benefits are subject to deductions.
The information you furnish on this form is voluntary. However, failure to provide this requested information
could prevent an accurate and timely decision on your claim and could result in the loss of some benefits.
We rarely use the information you supply for any purpose other than for making a determination about your
continuing entitlement to benefits. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another agency in accordance
with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal,
State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of Social Security programs (e.g., to the Bureau of the Census and private concerns under
contract to Social Security).
We may also use the information you provide in computer matching programs. Matching programs compare
our records with records kept by other Federal, State, or local government agencies. Information from these
matching programs can be used to establish or verify a person's eligibility for Federally-funded or administered
benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records Notices entitled,
Master Beneficiary Record, 60-0090 and Supplemental Security Income Record, 60-0103. These notices,
additional information regarding this form, and information regarding our programs and systems, are available
on-line at www.socialsecurity.gov or at your local Social Security office.

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 control number. We
estimate that it will take about 60 minutes to read the instructions, gather the facts, and answer the
questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The
office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.

Form SSA-7163A-F4 (08-2011) EF (08-2011)

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