Ssa-4184

FORM APPROVED
OMB NO. 0960-0487

SOelAL SECURITY ADMINISTRATION
RETIREMENT AND SURVIVORS INSURANCE

SELF-EMPLOYMENTICORPORATE OFFICER QUESTIONNAIRE
PRIVACY ACT NOTICE: This report is authorized by law under Section 2 0 3 of the Social Security Act. While
your response is voluntary, your cooperation is needed t o assure a correct determination of the amount of
Social Security benefits due you. We would give out the facts on this form without your consent only in
certain situations. For example, w e give out this information if a Federal law requires us t o or if your
Congressman or Senator needs the information t o answer questions you ask them.
PAPERWORK REDUCTION ACT STATEMENT: This information collection meets the clearance requirements
of 44 U.S.C. 53507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required t o answer these questions unless w e display a valid Office of Management and Budget control .
number. We estimate that it will take you about 2 0 minutes t o read the instructions, gather the necessary
facts, and answer the questions.

We are required t o verify retirement allegations and establish the amount of an individual's actual earnings.
You may be required t o submit individual tax returns, corporate tax returns, corporate minutes and
resolutions, bill of sale or transfer documents t o substantiate your statements.
Please complete the following questions. Any question which is not applicable t o you or your situation, please
mark NIA.
NAME

Part A

SOCIAL SECURITY NUMBER

- - Your

Work and Earnings

1. Describe the change in your employment situation. For example, reduction in salary, working fewer
hours, transfer or sale of business, etc.

IVOTE: If you transferred or sold the business, please complete Part C.
2. Effective date of the change reported in Question 1 above
3. Please give the name, address, phone number and type of business.
NAME
ADDRESS
PHONE
TYPE OF BUSINESS

FORM SSA-4184 (1-1991 ) (EF 01-2002)

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(OVER)

4. Is the business incorporated?
If so, date of incorporation.
Were you a corporate officer, or related to a corporate officer?

NOTE: If you were a corporate officer or related t o a corporate officer, please complete Part B.

5. How many employees work in the business?
FULL TIME

lPART

6. List the duties which you performed in the business prior t o the date shown in Item 2 on previous page.
Please include the number of hours worked (both at the place of business and away), your specific
responsibilities, decisions that you made, as well as tasks that you performed.

(Continue on separate sheet, if required)

7. Describe your duties after the date in Question 2 o n previous page. Please include the number of hours
that you work, decisions that you make, any consultation provided, and authority that you still hold, i.e.,
signing of checks, dealing w i t h other businesses as a representative of the business, making decisions,
etc. Describe h o w your responsibility has changed since the date in Item 2.

(Continue on separate sheet, if required)
FORM SSA-4184 (1-1 9 9 1 ) (EF 01-2002)

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8. Who has taken over your former duties?
NAME
DATE HIRED

RELATIONSHIP TO YOU
PRIOR EXPERIENCE

PRIOR SALARY

CURRENT SALARY

Questions 9 and 1 0 refer t o Income which you received prior t o the change in your work activities.

9. H o w much did you earn in self-employment prior t o the change in your work
activities?
10. If you received any other income from the business, please indicate by type and amount below:
SALARY

RENT

DIVIDENDS

BONUSES

REPAYMENT OF LOANS

EXPENSE ACCOUNT

OTHER (Please specify)

Questions 1 1 and 1 2 refer t o income which you expect t o receive after the change in your work activities.
11. How much do you expect t o earn in self-employment income based o n the change in your
work activities?
12. If you will receive any other income from the business, please indicate by type and amount below.
SALARY
I

DIVIDENDS

BONUSES
I

REPAYMENT OF LOANS

EXPENSE ACCOUNT

OTHER (Please specify)

Part B--Answer the Following Questions Only If the Business Was Incorporated
Questions 1 and 2 refer t o the period before the change in your work activities.
1. What was your position in the corporation?
2. Complete the following information regarding corporate officers:
NAME

1

RELATIONSHIP TO YOU

I

SALARY

PRESIDENT
VICE-PRESIDENT
I

I

I

I

I

I

SECRETARY
TREASURER

FORM SSA-4184 (1-1 991) (EF 0 1 - 2 0 0 2 )

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(OVER)

3. Is anyone related to you by blood or marriage receiving any remuneration from the corporation other
than salary?
YES
NO

If yes, indicate the type of remuneration and amounts:

Questions 4 and 5 refer to the period after the change in your work activities.

4. What is your current position in the corporation?
5. Complete the following information regarding corporate officers:
NAME

RELATIONSHIP TO YOU

PERCENTAGE OF
STOCK OWNED

SALARY

PRESIDENT
VICE-PRESIDENT
SECRETARY
TREASURER

6. Who determines what payments (e.g., salary, dividends, etc.) will be made to the corporate
officers?
Title
Part C--Complete This Part Only If You Have Sold Or Transferred Ownership Of the Business
SALE OR TRANSFER OF BUSllVESS
1. What is the date of the transfer?
2. What is the name of the person(s) to whom the business or farm (or interest in the same) was
transferred or rented?
3. Is the individual named above related to you by blood or marriage?
If so, how?

4. Is there a bill of sale, rental agreement, or other transfer document?
a. Has the above transaction been recorded?

YES

NO

YES

NO

YES

NO

b. If yes, where?
5. Will you participate in any capacity in the operation of the business or farm after
the transfer?
If yes, how?

6. What price did the new owner or partner pay for the transferred interest in the
business?
7. Will you receive any income under the transfer arrangement, such as a percenta e of the business
income, or a fixed salary?
YES
lV0

b

If yes, what Is the amount of the income?

FORM SSA-4184 (1-1 991) (EF 01-2002)

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REMARKS:

I know that anyone who makes or causes t o be made a false statement or representation of material fact in an
application or for use in determining a right t o payment under the Social Security Act commits a crime
punishable under Federal law and/or State law. I affirm that all information I have given in this document is
true.
Signature of Person Making Statement
SIGNATURE (FIRST NAME. MIDDLE INITIAL. LAST NAME)

DATE (MONTH, DAY, YEAR)

PHONE

MAILING ADDRESS
CITY AND STATE

FORM SSA-4184 (1-1991) (EF 01-2002)

(INCLUDE AREA CODE)

ZIP CODE

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