SSA-7163

Questionnaire About Employment Or Self-Employment Outside The United States

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PLEASE PRINT YOUR ANSWERS
NAME OF WORKER ON WHOSE ACCOUNT BENEFITS ARE BEING PAID
WORKER'S SOCIAL SECURITY CLAIM NUMBER
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NAME OF EMPLOYED OR SELF-EMPLOYED BENEFICIARY
BENEFICIARY'S SOCIAL SECURITY NUMBER (If different from worker's)
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/
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 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)

And much more...