Form SSA-1003 Statement of Agricultural Employer for Years 1988 and La

Form approved
OMS No. 0960-0036

SOCIAL SECURITY ADMINISTRATION
Refer to:

DATE
PERSON TO CONTACT
TELEPHONE NUMBER

(

)

RETURN ADDRESS (SSA OFFICE)

NAME OF WORKER

SOCIAL SECURITY NUMBER

ADDITIONAL IDENTIFYING INFORMATION (To be completed by Social Security Administration when applicable)

PRIVACY ACT/PAPERWORK ACT NOTICE: Section 205(a) of the Social Security Act
(42 U.S.C. 405(a)) allows us to ask for the information on this form. The information
you give us will be used to give the employee credit for wages earned. You do not
have to give us this information. However without the information, we will not be able
to give the employee credit for wages earned. We may give this information to the
Internal Revenue Service for tax-administration purposes or to the Department of
Justice for investigating and prosecuting violations of the Social Security Act.
COMPUTER MATCHING: We may also use the information you give us when we
match records by computer. Matching programs compare our records with those of
other Federal, State, or local government agencies. Many agencies may use matching
programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be
used or given out are available in Social Security offices. If you want to learn more
about this, contact any Social Security office.

See Revised PRA, Attached
PAPERWORK REDUCTION ACT STATEMENT: The Paperwork Reduction Act of 1995
requires us to notify you that this information collection is in accordance with the
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We
may not conduct or sponsor, and you are not required to respond to, a collection of
information unless it displays a valid OMS control number. We estimate that it will
take you about 5 minutes to complete this form. This includes the time it will take to
read the instructions, gather the necessary facts and fill out the form.

Enclosure

FORM SSA-1003·F3 (7-1992) (EF 8-2000)

Social Security Administration

Form Approved

TOE 320

OMB No. 0960-0036

STATEMENT OF AGRICULTURAL EMPLOYER FOR YEARS 1988 AND LATER

Work done by an agricultural employee is covered by the Social Security Act if the employee was paid $150 or more
in cash during the year by the same employer, or if the employer's expenditures for agricultural labor in such year
equal or exceed $2,500. The $2,500 a year test does not apply to an employee who receives less than $150 in
annual cash wages if the employee: (1) is a seasonal hand-harvest laborer paid on piece-rate basis; (2) commutes
daily from his or her home to the farm; and (3) has been employed in agriculture less than 13 weeks during the
preceding calendar year.
NAME OF WORKER

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _I_S_O_C_IA_L_S_E_C_U_R_IT_Y_N_U_M_B_ER

Year

WAGES PAID FOR:

_

Year

_

Year

_

_

Year

_

For the worker and tax years indicated above, please provide the following information:
1. Show total cash wages paid for this employee. Include any amount withheld for taxes. If no cash wages were paid in the
year(s) shown below, write "None." If you know that at least a certain amount was paid, but you do not know the exact
amount, write "Not less than" and show the amount.

Amount

Year

Year

Amount

$

$

$

$

2. Is your annual payroll for agricultural labor $2,500 or more?

DYes

DNa

3. Did you file employment tax return Form 943 with the Internal Revenue Service for
each year shown in item 1?

DYes

If "Yes," go to item 4. If "No," please identify the year(s) for which you did not file a tax return, and explain why you
did not.
Explanation:

4. Did you submit wage report Forms W-2 and W-3 or equivalent magnetic media
reports to the Social Security Administration for each year shown in item 1?

DYes

If "Yes," go to item 5. If "No," please identify the year(s) for which you did not file a wage report, and explain why
you did not.

Explanation:

FORM SSA-1003-F3 (7-1992) (EF 8·2000)

•

5. For reportts) which you did file with the Social Security Administration, were the wage

DYes

amounts shown in item 1 included in your report?

ONo

(a) If "Yes," please provide the following information.
Tax Year

Date Filed

Employer Name Shown
On Report

EIN Shown
On Report

(b\ If "No," show the amount of wages reported and explain why these amounts differ from the amounts shown in
item 1. If no wages were reported for this individual, please show "None," as appropriate, and explain why they
were not reported.

Year

Amount

Year

Amount

$

$

$

$

Explanation:

Additional Remarks:

I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or for
use in determining a right to payment under the Social Security Act commits a crime punishable under the Federal law by fine,
imprisonment or both. I affirm that all information I have given in this document is true.
6. EMPLOYEE'S OCCUPATION (e.g., foreman)

11. TYPE OF FARMING (e.g., dairy)

7. BUSINESS NAME OF EMPLOYER

12. EMPLOYER'S IDENTIFICATION NUMBER

8. STREET ADDRESS OF EMPLOYER

13. WRITTEN SIGNATURE OF EMPLOYER OR AUTHORIZED
PERSON

9. CITY

STATE

ZIP CODE

10. TELEPHONE NO. OF PERSON SIGNING THIS FORM

FORM SSA·1003·F3 (7-19921 (EF 8-2000)

14. PRINTED NAME AND TITLE OF PERSON SIGNING
ABOVE

15. DATE THIS FORM COMPLETED

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 30
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401