Form SSA-7104 Partnership Questionnaire

Form SSA-7104 (XX-XXXX)
Discontinue Prior Editions
Social Security Administration

Page of
OMB No. 0960-XXXX

PARTNERSHIP QUESTIONNAIRE
(For Determination of Coverage Under Title II of the Social Security Act)
NOTICE - All items must be answered. If you need more space, continue in "REMARKS" section or attach another sheet.
If the Internal Revenue Service has ruled as to whether a partnership exists, please furnish a copy of
the ruling.
NAME OF
FIRM

NAME OF WAGE-EARNER OR
SELF-EMPLOYED PERSON

ADDRESS OF
FIRM

SOCIAL SECURITY NUMBER

EMPLOYER
IDENTIFICATION NUMBER

THIS RELATES TO
THE PERIOD:FROM:

TO:

1. When was the partnership formed?
2. What is the nature of the business?

3. If the partnership agreement is in writing, please submit a copy with this completed form. (Include any changes or new
agreements.) If the partnership agreement is not in writing, give a statement below of the arrangements between the
partners as to their contributions, duties, responsibilities, rights, sharing of profits and losses, and dividing the business
property when the arrangement ends.

4. How much money or other property did each partner
contribute to the business?
5. Were the business books set up to show separate capital accounts for each partner?
6. What training and experience for the business does each partner have?

7. What services does each partner perform in connection with the business?

8. How much time does each partner devote to the business?

9. How are the profits or losses divided or shared?

yes

no

Form SSA-7104 (XX-XXXX)

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10. Enter below the amount shown as net earnings from self-employment from this business for each partner on the U.S.
partnership return or the individual tax return for the last three years:
NAME OF PARTNER

TELEPHONE NO.

SOCIAL SECURITY NO.

LAST
YEAR

TWO YEARS THREE YEARS
AGO
AGO

11. Whose name or names appears on the firm's:
a. truck or automobile licenses?
b. leases?
c. real property?
d. bank account?
e. business licenses and permits?
f. insurance policies?
g. business signs and advertisements?
h. bills?
i. letterheads?
j. orders for merchandise or supplies?
k. business contracts with others?
12. a. Who decides what purchases to make?
b. Who decides what prices to charge?
c. Who decides what repairs or improvements to make?
d. Who decides who to hire and how much to pay them?
e. Who decides when to borrow money for the business?
f. Who decides what advertising to do?
13. a. In what name does the firm file Social Security tax returns for its employees?

b. Who signs the returns?
c. What title does he/she use when signing the returns?
REMARKS - (Use this space for explaining any answers to the questions. If you need more space, attach another sheet.)

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.
SIGNATURE
STREET ADDRESS

TITLE
CITY

DATE
STATE

ZIP CODE

Form SSA-7104 (XX-XXXX)

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Privacy Act Statement
Collection and Use of Personal Information

See Revised
Privacy Act
Sections 205(b) and 205(c) of the Social Security Act, as amended, allow us to collect
this information.
Statement
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent us from making an accurate and timely decision on any claim filed.
We will use the information to make a determination of eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
1. To the Department of Treasury for: (a) collecting Social Security taxes or as otherwise pertinent to tax
and benefit payment provisions of the Social Security Act, or (b) investigating alleged theft, forgery, or
unlawful negotiation of Social Security checks; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social
Security Administration in the efficient administration of its programs.
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 Notices (SORN) 60-0089,
entitled Claims Folders Systems and 60-0090, entitled Master Beneficiary Record. Additional information
and a full listing of all our SORNs are available on our website at www.ssa.gov/privacy/sorn.html

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. The office is 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.