Ssa-1003-f3

Form SSA-1003 (11-2016) 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)

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 the information you
provide to give the employee credit for the correct amount of wages earned.
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 make a determination regarding claims and earnings
discrepancies. 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);
2. To facilitate statistical research, audit, or investigative activities necessary to assure 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 Systems of
Records Notice entitled, Earnings Recording and Self- Employment Income System, 60-0059. Additional information about this
and other system of records notices and our programs are 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 only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.
Enclosure

Form SSA-1003 (11-2016) UF

TOE 320

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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 (11-2016) 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