Form SSA-7157 Farm Arrangement Questionnaire

Social Security Administration

Farm Arrangement Questionnaire

TOE 420

FORM APPROVED
OMB No. 0960-0064

See Revised Privacy Act
Privacy Act Statement
Collection and Use of Personal Information
Statement Attached.
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.
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
1-800-325-0778). 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.
2. Social Security No.

1. Name of Self-Employed Person

3. Period Covered
From:
To:

4. Name and Address of Other Party to Arrangement

6. Description of Arrangement, Agreement, or Understand (If in writing, attach a copy)

A. Date Arrangement began

B. How long was Arrangement to last?

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.

Form SSA-7157-F4 (07-2015) uf (07-2015)

5. Family Relationship
(If none, write "None")

7. WORK - (Describe in detail the work performed by each party)
KIND OF WORK - (Include such activities as buying and selling as Date Work Began
well as physical labor)

8. INSPECTIONS

Date Work Ended

Total Hours Worked

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 (07-2015) uf (07-2015)

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 paidany 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.)

11. Expenses - (List major items)
EXPENSES PAID OR ADVANCED BY PERSON
NAMED IN ITEM 1.

Form SSA-7157-F4 (07-2015) uf (07-2015)

Amount

EXPENSES PAID OR ADVANCED BY
OTHER PARTY

Amount

12. 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
EXPENSES PAID OR ADVANCED BY PERSON
NAMED IN ITEM 1.

Amount

EXPENSES PAID OR ADVANCED BY
OTHER PARTY

Amount

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

Form SSA-7157-F4 (07-2015) uf (07-2015)