Form SSA-7157 Farm Arrangement Questionnaire

SOCIAL SECURITY ADMINISTRATION

FORM APPROVED
OMB No. 0960-0064

TOE 420

FARM ARRANGEMENT QUESTIONNAIRE

PRIVACY ACT: The questions on this form are authorized by section 211 (a)(1) 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 to
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.

See Revised Privacy Act
Statement & PRA

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 benefit; (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 conduct sponsor, and you are not
required to respond to, a collection of information unless it displays a valid OMB 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, gather the necessary facts, and fill out the form.
1.

NAME OF SELF-EMPLOYED PERSON

2. SOCIAL SECURITY NO.

3. PERIOD COVERED
FROM:
TO:

4.

NAME AND ADDRESS OF OTHER PARTY TO ARRANGEMENT

6.

DESCRIPTION OF ARRANGEMENT, AGREEMENT, OR UNDERSTANDING (If in writing, attach a copy)

A.

DATE ARRANGEMENT BEGAN

C.

CROPS AND LIVESTOCK TO BE PRODUCED (List)

D.

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

E.

OTHER FEATURES OR CHANGES IN ARRANGEMENT.

7.

B.

5.

FAMILY RELATIONSHIP
(If none, write "None")

HOW LONG WAS ARRANGEMENT TO LAST?

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

KIND OF WORK - (Include such activities as buying and selling as well as physical labor)

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

DATE WORK
BEGAN

DATE WORK
ENDED

TOTAL HRS.
WORKED

Page 1

8.

INSPECTIONS

9.

ADVICE AND CONSULTATION

(Indicate for each stage below what inspections were made by the person
named In Item 1, how often, purpose and changes resulting. If there was no
inspection during a particular stage, indicate, "None.")

(Indicate for each stage below what was talked about, how often meetings
were held, advice given, and action taken. If there was not advice and
consultation during a particular stage, indicate "None.")

CROP AND LIVESTOCK PLANNING

CROP AND LIVESTOCK PLANNING

GROUND BREAKING AND PLANTING

GROUND BREAKING AND PLANTING

GROWING PERIOD

GROWING PERIOD

HARVESTING AND MARKETING

HARVESTING AND MARKETING

ANY OTHER NOT DESCRIBED ABOVE

ANY OTHER NOT DESCRIBED ABOVE

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

Page 2

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, 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

GROWING PERIOD

HARVESTING AND MARKETING

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

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

Page 3

EXPENSES - (List Major Items)

11.
EXPENSES PAID OR ADVANCED BY PERSON NAMED IN ITEM 1.

AMOUNT

EXPENSES PAID OR ADVANCED BY OTHER PARTY

AMOUNT

CAPITAL CONTRIBUTIONS

12.

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 1

VALUE

BY OTHER PARTY

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, write "None.")
(A) BUSINESS LICENSES AND PERMITS

(E) BILLS TO CUSTOMERS FOR SALES

(B) FEDERAL AGRICULTURAL PROGRAM AGREEMENTS

(F) INSURANCE POLICIES

(C) MEMBERSHIP IN FARM COOPERATIVES

(G) ADVERTISEMENTS AND SIGNS

(D) BILLS FROM CREDITORS FOR PURCHASES

(H) BUSINESS 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.
DATE

SIGNATURE

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

Page 4

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 OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 211(a)(1) of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to determine if farm rental earnings
should be included in your Social Security earnings record. Furnishing us this information is
voluntary. However, failing to provide us with all or part of the information may prevent an
accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to reconcile Social
Security earnings records. However, we may use the information for the administration of our
programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0059, entitled, Earnings Record and
Self-Employment Income System and 60-0089, entitled, Claims Folder System. Additional
information about these and other system of records notices and our programs is available online
at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.