Form SSA-1002 (revised) SSA-1002 (revised) Statement of Agricultural Employer (Years Prior to 1988)

Form Approved
OMB 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)

See Revise Privacy Act
Statement
PRIVACY ACT/PAPERWORK ACT NOTICE: Section 205(a) of the 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 Statement, 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.

FORM

SSA-1002-F3

(07-1992) EF (05-2002)

Social Security Administration

Form Approved
OMB No. 0960-0036

TOE 320

STATEMENT OF AGRICULTURAL EMPLOYER (YEARS PRIOR TO 1988)

Work done by an agricultural employee was 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 employee worked for the same
employer on 20 or more days in a year and was paid cash wages figured on a TIME BASIS (hour, day,
week, month, etc.) FOR YEARS PRIOR TO 1988. If you believe any of the amounts you enter are not
wages or any of the employment is not covered by the Social Security Act, outline your reasons under
"Remarks" on the back of this form.
This is to certify that cash wages for agricultural labor in the amounts shown were paid during the
calendar year(s) checked below to:
NAME OF WORKER

I_S_O_C_IA_L_S_E_C_U_R_IT_Y_N_U_M_B_ER

_

1. Show the total cash wages paid this employee for agricultural services (including domestic service on
a farm). Include any amount withheld for tax. If no wages were paid in the periods checked below,
write "None." If the amounts are unknown, write "Unknown" and answer question 2.
D

WAGES PAID YEAR 19

$

DWAGES PAID YEAR 19_ DWAGES PAID YEAR 1 9 _ D

$

$

WAGES PAID YEAR 19 _

$

If the amount of wages shown for any year is less than $150, answer question 2.
2. Was this employee paid on a TIME basis? (By the hour, day, week, month, etc.)
If "Yes," did the employee work for you on 20 or more days in the year or years?

DYes
DYes

D No
D No

If your answer to item 2 does not apply to all years shown, please explain in "Remarks" on back of this
form.
NOTE: COMPLETE ITEMS 3-12 IN ALL CASES

D COMPLETE ITEMS 13,14 and 15 on the back of this form

D

DO NOT COMPLETE ITEMS 13,14 and 15.

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.
3. EMPLOYEE'S OCCUPATION (For example, ReId Worker,
Milker, Herdsman)

8. NATURE OF BUSINESS (For example, Daily Farm,

Orchard, Cattle Ranch).

4. BUSINESS NAME OF EMPLOYER (Type or Print, if

different from above)

5. EMPLOYER'S FEDERAL IDENTIFICATION NO.

9. WRITTEN SIGNATURE OF EMPLOYER OR AUTHORIZED
EMPLOYEE OF FIRM

6. STREET ADDRESS OF EMPLOYER (If different from above)

10. TITLE OF PERSON SIGNING ABOVE

7. CITY (If different from above)

FORM

SSA-1002-F3

STATE ZIP CODE

107-1992) EF 105-2002)

11. TELEPHONE NO. OF
INDIVIDUAL COMPLETING
FORM (INCLUDE AREA CODE)

12. DATE THIS STATEMENT
FILLED OUT

(over)

13. Did you file employment tax return(s) (Form 943) for each period
shown in item 1 of this form?

DYes

o

No

If "No," please identify the period for which no return was filed and state why you did not do so.

14.

For returns which you did file, were the wages listed on this form
included in your return?
(a) If "Yes," please furnish the following information:

Date return(s) were filed:

DYes

0

No

Period Date
Filed

Page and line number of report
Page No.

where this employee was reported
Line No.

(if filed on Form 943)

(Please use another sheet if more entries are needed)
(b) If "No," please state below the amount of wages reported and why these wages differ from the
amounts shown in item 1 of this form. If no wages were reported, show "none" and explain
below why no wages were reported.

~11111111111---+--1

Period

Amount
Reported

(Please use another sheet if more entries are needed.)
Explanation:

15.

(a) Did you have employees other than this wage earner during the above
period?
(b) If "Yes," was there a reporting problem with regard to any these other
employees for the above periods?

Remarks:

FORM SSA-1 002-F3 107-1992) EF 105-2002)

DYes

DYes

SSA will insert the following revised Privacy Act Statement into the form
at its next scheduled reprinting:
Statement of Agricultural Employer (Years Prior to 1988), SSA-1002-F3
Privacy Act Statement
Collection and Use of Personal Information

Section 205(a) of the Social Security Act, as amended, authorizes us to collect this
information. We will use this information to give the employee credit for the correct
amount of wages. Completion of this form is voluntary; however, without the
information we may not be able to give the employee credit for the correct amount of
wages earned.
We rarely use the information you supply for any purpose other than what is stated
above. 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.
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 System of Records
Notice entitled, Earnings Recording and Self-Employment Income System (60-0059).
This notice, additional information regarding this form, routine uses of information, and
our programs and systems are available on-line at www.socialsecurity.gov or at your
local Social Security office.

SSA will insert the following revised PRA Statement 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 relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.