Form SSA-1003 Statement of Agricultural Employer for Years 1988 and La

Form SSA-1003 (05-2020) UF
Discontinue Prior Editions
Social Security Administration
Refer to:

Page 1 of 3
OMB No. 0960-0036
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 Revised
Privacy Act
Statement
Sections 205(a) and 205(c)(2)(A) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this
Privacy Act Statement
Collection and Use of Personal Information

information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on
any claim filed.
We will use the information to give the employee credit for the correct amount of wages earned. We may also share the
information for the following purposes, called routine uses:
1. To employers or former employers, including State Social Security administrators, for correcting and reconstructing State
employee earnings records and for Social Security purposes; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of
its programs. We will disclose information under this routine use only in situations in which SSA may enter into a contractual
or similar agreement with a third party to assist in accomplishing an agency function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0059, entitled Earnings
Recordings and Self-Employment Income System. Additional information and a full listing of all our SORNs are available on our
website at www.socialsecurity.gov/foia/bluebook.

See Revised PRA
meets the requirements of 44 U.S.C. § 3507, as amended by
Paperwork Reduction Act Statement - This information collection
Statement
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.
Enclosure

Form SSA-1003 (05-2020) UF

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Statement of Agricultural Employer Years 1988 and Later
Work done by an agricultural employee is 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 employer's expenditures for agricultural labor in such year equal or exceed
$2,500. The $2,500 a year test does not apply to an employee who receives less than $150 in annual cash wages if the
employee: (1) is a seasonal hand-harvest laborer paid on piece-rate basis; (2) commutes daily from his or her home to the farm;
and (3) has been employed in agriculture less than 13 weeks during the preceding calendar year.
Name of Worker

Wages Paid For:

Social Security Number

Year

Year

Year

Year

For worker and tax years indicated above, please provide the following information:
1. Show total cash wages paid for this employee. Include any amount withheld for taxes. If no cash wages were paid in the
year(s) shown below, write "None." If you know that at least a certain amount was paid, but you do not know the exact amount,
write "Not less than" and show the amount.
Year

Amount

Year

Amount

$

$

$

$

2. Is your annual payroll for agricultural labor $2,500 or more?

Yes

3. Did you file employment tax return Form 943 with the Internal Revenue Service
for each year shown in item 1?

No

Yes

No

If "Yes," go to item 4. If "No," please identify the year(s) for which you did not file a tax return, and explain why you did not.
Explanation:

4. Did you submit wage report Forms W-2 and W-3 or equivalent magnetic media reports to the
Social Security Administration for each year shown in item 1?

Yes

No

If "Yes," go to item 5. If "No," please identify the year(s) for which you did not file a wage report, and explain why you did not.
Explanation:

Form SSA-1003 (05-2020) UF

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5. For report(s) which you did file with the Social Security Administration,
were the wage amounts shown in item 1 included in your report?

Yes

No

(a) If "Yes," please provide the following information.
Tax Year

Date Filed

Employer Name
Shown on Report

EIN Shown on Report

(b) If "No," show the amount of wages reported and explain why these amounts differ from the amounts shown in item 1. If no
wages were reported for this individual, please show "None," as appropriate , and explain why they were not reported.
Year

Amount

Year

Amount

$

$

$

$

Explanation:

Additional Remarks:

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements
or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false
statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a
fine or imprisonment.
6. Employee's Occupation (e.g., Foreman)

11. Type of Farming (e.g., Dairy)

7. Business Name of Employer

12. Employer's Identification Number

8. Street Address of Employer

13. Written Signature of Employer or Authorized Person

9. City

State

10. Telephone No. of Person Signing This Form

Zip Code

14. Printed Name and Title of Person Signing Above

15. Date This Form Completed