SSA-7157 Farm Arrangement Questionnaire

Form SSA-7157 (06-2020)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0064

Farm Arrangement Questionnaire
Privacy Act Statement
Collection and Use of Personal InformationSee Revised
Section 211(a)(1) of the Social Security Act, as amended, allows us to collect this information.
Furnishing
Privacy
Act us this information is
voluntary. However, failing to provide all or part of the information may prevent us from making
an accurate
Statement
and and timely decision
on any claim for benefits. We will use the information you provide to help us determine ifPRA
farm rental
earnings should be included
Statement
in your Social Security earnings record. We may also share the information for the following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA)
in the efficient administration of its programs.
2. To student volunteers, individuals working under a personal services contract, and other workers who technically do not have
the status of Federal employees, when they are performing work for SSA, as authorized by law, and they need access to
personally identifiable information in SSA records in order to perform their assigned Agency functions.
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 (SORNs)
60-0059, entitled Earnings Recording and Self-Employment Income System and 60- 0089, entitled Claims Folders System.
Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
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.
You can find your local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also 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.
1. Name of Self-Employed Person

2. Social Security No.

Period Covered: From:
To:

4. Name and Address of Other Party to Arrangement

5. Family Relationship
(If none, write "None")

6. Description of Arrangement, Agreement, or Understanding (if in writing, attach a copy)

A. Date Arrangement Began

B. How long was Arrangement to last?

C. Crops and Livestock to be produced (List)

D. How income and expenses (or net profits and losses) were to be shared.

E. Other features or changes in arrangement.

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7. WORK - (Describe in detail the work performed by each party)

KIND OF WORK - (Include such activities as buying and selling as Date Work Began
well as physical labor)

8. INSPECTIONS

Date Work Ended

Total Hours Worked

9. ADVICE AND CONSULTATION

(Indicate for each stage below what inspections were made by
the person named In Item 1, how often, purpose and changes
resulting. If there was no inspection during a particular stage,
indicate, "None.")

(Indicate for each stage below what was talked about, how often
meetings were held, advice given, and action taken. If there was
not advice and consultation during a particular stage, indicate
"None.")

Crop and Livestock Planning

Crop and Livestock Planning

Ground Breaking and Planting

Ground Breaking and Planting

Growing Period

Growing Period

Harvesting and Marketing

Harvesting and Marketing

Any other not described above

Any other not described above

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10. MANAGEMENT DECISIONS (Indicate what decisions each party made during the stages described below, and what
decisions were made jointly. Include such items as what, when, and how to plant, cultivate, spray, harvest, etc.; when, what,
where to buy and sell; agricultural standards to follow; participation in government programs; who negotiated purchases and
sales; who decided what help to hire and how much to pay them, and who supervised and paidany additional help, etc.)
Crop and Livestock Planning

Ground Breaking and Planting

Growing Period

Harvesting and Marketing

Additional Management Decision (Include any decisions not described above. If more space is needed, attach a separate sheet.)

11. Expenses - (List major items)
EXPENSES PAID OR ADVANCED BY PERSON
NAMED IN ITEM 1.

Amount

EXPENSES PAID OR ADVANCED BY
OTHER PARTY

Amount

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12. Capital Contributions

NAME OF PERSON WHO FURNISHED LAND, BUILDINGS, AND IMPROVEMENTS ON THE LAND
MAJOR ITEMS OF MACHINERY, EQUIPMENT, AND LIVESTOCK CONTRIBUTED TO PRODUCTION ACTIVITIES
EXPENSES PAID OR ADVANCED BY PERSON
NAMED IN ITEM 1.

Amount

EXPENSES PAID OR ADVANCED BY
OTHER PARTY

Amount

13. FINANCIAL OPERATION. (Describe the financial operation. Was a business bank account maintained? In whose name(s)? Who
can draw on the account? For what purpose? Who decided if and when to borrow? In whose name were any loans taken, etc.?)

14. WHOSE NAME OR NAMES APPEAR IN CONNECTION WITH THE FOLLOWING: (If not applicable, write "None.")
(A) BUSINESS LICENSES AND PERMITS

(E) BILLS TO CUSTOMERS FOR SALES

(B) FEDERAL AGRICULTURAL PROGRAM AGREEMENTS

(F) INSURANCE POLICIES

(C) MEMBERSHIP IN FARM COOPERATIVES

(G) ADVERTISEMENTS AND SIGNS

(D) BILLS FROM CREDITORS FOR PURCHASES

(H) BUSINESS CONTRACTS WITH OTHERS

IF ADDITIONAL SPACE IS NEEDED, USE SEPARATE SHEET
I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or for
use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law by fine,
imprisonment or both. I affirm that all information I have given in this document is true.
Date

Signature