Form SSA-1002 Statement of Agricultural Employer (Years Prior to 1988)

Form SSA-1002 (06-2020) UF
Discontinue Prior Editions
Social Security Administration
Refer to:

Page of
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

See Revised
Privacy Act
Sections 205(a) and 205(c)(2)(A) of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this
Statement
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.

Paperwork Reduction Act Statement

See Revised PRA
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.

Form SSA-1002 (06-2020) UF

Page of

Statement of Agricultural Employer (Years Prior to 1988)
Work done by an agricultural employee was 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 employee worked for the same employer on 20 or more days in a year and was
paid cash wages figured on a TIME BASIS (hour, day, week, month, etc.) FOR YEARS PRIOR TO 1988. If you believe any of
the amounts you enter are not wages or any of the employment is not covered by the Social Security Act, outline your reasons
under "Remarks".
This is to certify that cash wages for agricultural labor in the amounts shown were paid during the calendar year(s) checked
below to:
Name of Worker

Social Security Number

1. Show the total cash wages paid this employee for agricultural services (including domestic service on a farm). Include any
amount withheld for tax. If no wages were paid in the periods checked below, write "None." If the amounts are unknown, write
"Unknown" and answer question 2.
Wages paid Year 19

Wages paid Year 19

Wages paid Year 19

Wages paid Year 19

If the amount of wages shown for any year is less than $150, answer question 2.
2. Was this employee paid on a TIME basis? (By the hour, day, week, month, etc.)
If "Yes," did the employee work for you on 20 or more days in the year or years?
If your answer to item 2 does not apply to all years shown, please explain in "Remarks"

Yes

No

Yes

No

NOTE: Complete items 3 - 12 in all cases
Complete items 13, 14, and 15

Do not complete items 13, 14, and 15

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.
3. Employee's Occupation (For example, Field Worker, Milker, Herdsman)

5. Employer's Federal
Identification Number

4. Business Name of Employer (Type or Print, if different from above)

6. Street Address of Employer (if different from above)

7. City (if different from above)

State ZIP Code

8. Nature of Business (For example, Dairy Farm, Orchard, Cattle Ranch)

9. Written Signature of Employer or Authorized Employee of Firm

10. Title of Person Signing Above

11. Telephone Number of Individual Completing Form (Include Area Code)

12. Date this Statement Filled Out

13. Did you file employment tax return(s)(Form 943) for each period shown in item 1 of this form?
If "No," please identify the period for which no return was filed and state why you did not do so.

Yes

No

Form SSA-1002 (06-2020) UF
14. For returns which you did file, were the wages listed on this form included in your return?
(a) If "Yes," please furnish the following information:
Date return(s) were filed:

Page of
Yes

No

Period Date
Filed

Page and line number of Page Number
report where this
employee was reported
Line Number
(if filed on Form 943)
(Please use another sheet if more entries are needed)
(b) If "No," please state below the amount of wages reported and why these wages differ from the amounts shown in item 1
of this form. If no wages were reported, show "none" and explain below why no wages were reported.
Period
Amount
Reported
(Please use another sheet if more entries are needed)
Explanation:

15. (a) Did you have employees other than this wage earner during the above period?
(b) If "Yes," was there a reporting problem with regard to any these other employees
for the above periods?
Remarks:

Yes

No

Yes

No