SSA-7156 Farm Self-Employment

Form SSA-7156 (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0061

TOE 420

FARM SELF-EMPLOYMENT QUESTIONNAIRE
1. NAME OF SELF-EMPLOYED PERSON
2. THIS RELATES TO PERIOD (DATES)
From:

To:

SOCIAL SECURITY NUMBER
Did you live on the farm during
this period?
YES
NO

If "No," how far from the farm did you live?

3. HOW LARGE WAS THE FARMING OPERATION DURING THIS PERIOD? (Total acreage, acreage cultivated,
crop allotments, usual size of herds, etc.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

4. WHAT WAS YOUR STATUS WITH REGARD TO THIS FARMING OPERATION?
(Check appropriate box or boxes according to local terminology)
OWNER
OWNER-OPERATOR
PARTNER
LANDLORD
TENANT

SHARECROPPER

OTHER

5. DID ANY OTHER PERSON WORK OR HELP
(A) NAME OF THE OTHER PERSON(S) AND FAMILY
WORK THE FARM? IF "YES." ANSWER (A). (B). (C).
RELATIONSHIP, IF ANY.
YES

NO

(B) WHAT DID THE OTHER PERSON DO IN CONNECTION WITH THE FARMING OPERATION?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
(C) HOW WAS THE OTHER PERSON PAID?
CROP OR LIVESTOCK SHARE
CASH WAGES
ROOM & BOARD
LANDLORD
6. WAS ANY RENTAL INCOME (EITHER CASH OR CROP SHARE) INCLUDED IN FIGURING YOUR NET EARNINGS FROM
SELF-EMPLOYMENT FOR THIS PERIOD?
YES

NO

7. HAS ANY INCOME FROM THE SALE OF LIVESTOCK NOT HELD FOR SALE BEEN
INCLUDED IN FIGURING YOUR NET EARNINGS FROM SELF-EMPLOYMENT. (NOT HELD
FOR SALE REFERS TO LIVESTOCK SUCH AS WORK, DAIRY, OR BREEDING ANIMALS
HELD PRIMARILY FOR THE PRODUCTION OF OTHER FARM COMMODITIES.)

YES

IF "YES," ENTER THE
AMOUNT OF SUCH
INCOME

NO

REMARKS:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

Form SSA-7156 (XX-XXXX) UF
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Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in determining a
payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or
continued right to payment, or submits or causes to be submitted any false statement or document knowing the same to contain
any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be
subject to administrative sanctions.
NAME OF PERSON MAKING STATEMENT

DATE
Telephone Number(include area code)

MAILING ADDRESS (Number and street, Apt. No., P.O. Box, or Rural Route)

CITY AND STATE

ZIP CODE

Enter Name of Country (if any) - in which you
now live

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b)(1), 205(c)(2)(A) and 211(a) of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and
timely decision on the claim for benefits.
We will use the information to determine your eligibility for benefits. We may also share your information for the following
purposes, called routine uses:
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration in
the efficient administration of its programs; and
• To student volunteers 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 (SORN) 60-0089, entitled Claims
Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784 and 60-0090, entitled Master
Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826. Additional information, and a full listing of all of
our SORNs, is available on our website at www.ssa.gov/privacy/.

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 10 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.