SSA-7163A

Supplemental Statement Regarding Farming Activities Of Person Living Outside The U.S.A.

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(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.)
Form Approved OMB No. 0960-0103        TOE 220

PAGE 1 NAME OF BENEFICIARY
SOCIAL SECURITY CLAIM NUMBER
1a. GIVE THE DATE YOUR FARM RESIDENCE OR OPERATION BEGAN OUTSIDE THE U.S.
1b. GIVE THE DATE IT ENDED
1c. HOW DID IT END? (Sale, lease of land, etc.)

2a. DO YOU OWN THE FARM? YES - NO
(If "Yes," go on to question 3)
2b. GIVE NAME OF THE OWNER AND INDICATE HIS RELATIONSHIP TO YOU
2c. EXPLAIN THE TYPE OF AGREEMENT OR CONTRACT YOU HAVE WITH THE OWNER
2d. HOW ARE YOU PAID? (Check one)
DAILY - WEEKLY - MONTHLY - OTHER (Specify)

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.
PRESENT YEAR
a. TYPES OF LIVESTOCK AND POULTRY - NO. OF HEAD
b. TYPES OF CROPS
LAND AREA USED - YIELD - LAST YEAR
TYPES OF LIVESTOCK AND POULTRY
NO. OF HEAD
TYPES OF CROPS
LAND AREA USED - YIELD
6. Give below the following information about the livestock, poultry, crops, and produce SOLD.
PRESENT YEAR
ITEMS
QUANTITY
AMT. RECEIVED (local currency)
LAST YEAR
ITEMS
QUANTITY
AMT. RECEIVED (local currency)

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