Form SSA-7157 Farm Arrangement Questionnaire

FORM APPROVED
OMS No. 0960-0064

TOE 420

SOCIAL SECURITY ADMINISTRATION

FARM ARRANGEMENT QUESTIONNAIRE
PRIVACY ACT: The questions on this form are authorized by section 211 la)(l) of the Social Security Act, as amended (42U.S.C. 411 (a)(1)).While it is
voluntary for you to complete this form, failure to answer the following questions would cause the Social Security Administration to make a decision on
your claim based on the information available. The information given by you on this form will be used to determine if the income you received is covered for
Social Security purpose and may affect your eligibility for Social Security benefits.
The information collected is needed to make that determination. The Information on this form may be disclosed by the Social Security Administration to
another person or agency for the following purposes: (1) to assist the Social Security Administration in establishing the right of a beneficiary to Social
Security benefits; (2) to facilitate statistical research and audit activities necessary to ensure the Integrity and Improvement of the Social Security programs;
and (3) comply with laws requiring the exchange of information between the Social Security Administration and another agency.
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 conductor 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 30 minutes to
complete this form. This includes the time it will take to read the instructions. oather the necessarv facts and fill out the form.
1.

NAME OF SELF-EMPLOYED PERSON

2.

SOCIAL SECURITY NO.

3. PERIOD COVERED
FROM:
TO:

4.

5.

NAME AND ADDRESS OF OTHER PARTY TO ARRANGEMENT.

FAMILY RELATIONSHIP
(If none. write 'None")

6.

DESCRIPTION OF ARRANGEMENT. AGREEMENT OR UNDERSTANDING

A.

DATE ARRANGEMENT BEGAN

C.

CROPS AND LIVESTOCK TO BE PRODUCED (List)

B.

(If

in writing. attach a copy)

HOW LONG WAS ARRANGEMENT TO LAST?

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.......

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D.

HOW INCOME AND EXPENSES lOR NET PROFITS AND LOSSES) WERE TO BE SHARED.

E.

OTHER FEATURES OR CHANGES IN ARRANGEMENT.

7

WORK - (Describe in detail the work performed by each party)

KIND OF WORK

~-

...

(Include such activities 85 buying and selling 85 well as physical labor!

DATE WORK
BEGAN

DATE WORK
ENDED

TOTAL HRS.
WORKED

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Form SSA-7157-F4 (1-1985) (EF 7-2000)
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8.

ADVICE AND CONSULTATION

9.

INSPECTIONS

(Indicate for each stage below what inspections were made by the person
named In Item " how otten, purpose and changes resulting. If there was no
inspection during a particular stage, indicate "None. "J

(Indicate for each stagfl below what was talked about, how often meetings
were held, advice given, and action taken. If there was not advice and
Iconsultation during a particular stage, indicate "None."J
CROP AND LIVESTOCK PLANNING

CROP AND LIVESTOCK PLANNING

_M_

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........

GROUND BREAKING AND PLANTING

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GROUND BREADING AND PLANTING

....... _ - ­

GROWING PERIOD

GROWING PERIOD

-_.....

HARVESTING AND MARKETING

HARVESTING AND MARKETING

....... _ - - - - - _ .....

•••••

_ _

ANY OTHER NOT DESCRIBED ABOVE.

M_______

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ANY OTHER NOT DESCRIBED ABOVE.

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Form SSA-7157-F4 (1-1985) (EF 7-2000)

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10. MANAGEMENT DECISIONS (Indicate what decisions each party made during the stages described below,and what
decisions were made jointly. Include such items as what, when, where and how to plant, cultivate, spray, harvest, etc.;
when, what, where to buy and sell; agricultural standards to follow; participation in government programs; who
negotiated purchases and sales; who decided what help to hire and how much to pay them, and who supervised and paid
any additional help, etc.)
CROP AND LIVESTOCK PLANNING

GROUND BREAKING AND PLANTING

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.......

- - -..

~

- - - ­

GROWING PERIOD

- - - - - - - - - - - - - - - - - - - - - - - - - - -..- ­

HARVESTING AND MARKETING

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.......

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......

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ADDITIONAL MANAGEMENT DECISION {Include any decisions not described above. If more space is needed, attach a separate sheet. I

Form SSA-7157-F4 (1-1985) (EF 7-2000)

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EXPENSES

EXPENSES PAID OR ADVANCED BY PERSON NAMED IN ITEM 1.

12

(List Major Items)
EXPENSES PAID OR ADVANCED BY OTHER PARTY

AMOUNT

AMOUNT

CAPITAL CONTRIBUTIONS

NAME OF PERSON WHO FURNISHED lAND, BUilDINGS AND IMPROVEMENTS ON THE lAND.

MAJOR ITEMS OF MACHINERY, EQUIPMENT, AND LIVESTOCK CONTRIBUTED TO PRODUCTION ACTIVITIES.
BY PERSON NAMED IN ITEM I

BY OTHER PARTY

VALUE

VALUE

13. FINANCIAL OPERATION. (Describe the financial operation. Was a business bank account maintained? In whose name(s)? Who can
draw on the account? For what purpose? Who decided if and when to borrow? In whose name were any loans taken, etc.?)

14. WHOSE NAME OR NAMES APPEAR IN CONNECTION WITH THE FOllOWING: !If not applicable, wn'te "None. oJ
(A)

BUSINESS LICENSES AND PERMITS.

IE)

BillS TO CUSTOMERS FOR SALES

(B)

FEDERAL AGRICULTURAL PROGRAM AGREEMENTS

IF)

INSURANCE POLICIES.

(C)

MEMBERSHIP IN FARM COOPERATIVES.

(G)

ADVERTISEMENTS AND SIGNS.

(D)

BillS FROM CREDITORS FOR PURCHASES

(H)

BUSlNESS CONTRACTS WITH OTHERS.

IF ADDITIONAL SPACE IS NEEDED, USE SEPARATE SHEET

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 Federal law
by fine, imprisonment or both. I affirm that all information I have given in this document is true.

Form SSA-7167-F4 (1-1985) (EF 7-2000)

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