Current SSA-7156

Form SSA-7156 (01-2024) UF
Social Security Administration

Page 1 of 2
OMB No. 0960-0061

TOE 420

FARM SELF-EMPLOYMENT QUESTIONNAIRE
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/.
1. NAME OF SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

2. THIS RELATES TO PERIOD (DATES)

Did you live on the farm
during this period?

From:

To:

Yes

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

No

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
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

OTHER

NO

(B) WHAT DID THE OTHER PERSON DO IN CONNECTION WITH THE FARMING OPERATION?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

Form SSA-7156 (01-2024) UF
(C) HOW WAS THE OTHER PERSON PAID?

CROP OR LIVESTOCK SHARE

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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
YES
NO
FARM COMMODITIES.)

IF "YES," ENTER THE AMOUNT
OF SUCH INCOME

REMARKS:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
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.
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. I understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.

SIGNATURE OF PERSON MAKING STATEMENT
SIGNATURE (First name, middle initial, last name) (Write in ink)

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

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the person making the statement must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (Number and street, City, & Zip Code)

ADDRESS (Number and street, City, & Zip Code)