Current Version SSA-7104

Form Approved
OMB No. 0960-0025

Social Security Administration

PARTNERSHIP QUESTIONNAIRE
(For Determination of Coverage Under Title II of the Social Security Act)
PAPERWORK REDUCTION ACT NOTICE: The Social Security Administration is authorized to collect the information on this form under section 205(b) and 205(c) of the
Social Security Act. Giving us this information is voluntary. You do not have to do it, but we may not be able to pay benefits to you or pay the correct amount (or
whatever) unless you give us this information.
We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows
us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices. If you want to learn more
about this, contact any Social Security Office.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the
Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB
control number. We estimate that it will take 30 minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary facts
and fill out the form.

NOTICE - All items must be answered. If you need more space, continue in "REMARKS" section on the reverse of this form
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:

1. When was the partnership formed?

/

/

TO:

u

2. What is the nature of the business?
3. If the partnership agreement is in writing, please submit a copy. (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?
u
5. Were the business books set up to show separate
Yes
capital accounts for each partner?
u
6. What training and experience for the business does each partner have?

No

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?
FORM SSA-7104 (4-1986) EF (7-2000) Destroy prior editions

(OVER)

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 AGO

THREE YEARS AGO

11. Whose name or names appears on the firm's:
a. truck or
automobile licenses?
b. leases?
u

c.
d.

real property?

u

bank account?

u

e. business licenses
and permits?
f.
insurance policies?
g. business signs and
advertisements?
h.
bills?
i.

letterheads?

u
u
u
u
u

j. orders for merchandise
or supplies?
u
k. business contracts
with others?
u
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?

u
u

u
u
u
u

13. a. In what name does the firm file Social Security tax returns for its employees?
b.

Who signs the returns?

u

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

I certify that all copies of contracts and all statements submitted herewith are true, correct, and complete
to the best of my knowledge and belief.
SIGNATURE

STREET ADDRESS
FORM SSA-7104 (4/86)

TITLE

CITY

DATE
STATE

ZIP CODE