Free Farm Self-Employment Questionnaire - SSA-7156 - Federal

SOCIAL SECURITY ADMINISTRATION Privacy Act/Paperwork Act Notice: The questions on this form are authorized by section 211 (a) of the Social Security Act, as amended (42 U.S.C. 411). While it is not mandatory for you to complete this form, failure to answer the following questions would cause the Social Security Administration to make a decision on your claim based on the information available. The information that you provide on this form will be used to determine if you are self-employed as a farmer, and it may affect your eligibility for social security benefits.
1. NAME OF SELF-EMPLOYED PERSON

TOE 420

Form Approved OMB No. 0960-0061

FARM SELF-EMPLOYMENT QUESTIONNAIRE
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. These and other reasons why information about you may be used or given out are explained in the Federal Register. If you want to learn more about this, contact any Social Security office.
SOCIAL SECURITY NUMBER

2. FROM

THIS RELATES TO PERIOD (DATES) TO

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) OWNEROPERATOR OTHER (Specify)

OWNER 5.

PARTNER

LANDLORD

TENANT

SHARECROPPER

DID ANY OTHER PERSON WORK OR HELP WORK THE FARM? IF "YES." ANSWER (A). (B). (C). YES NO

(A) NAME OF THE OTHER PERSON(S) AND FAMILY RELATIONSHIP. IF ANY.

(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 OTHER (Specify)

Form SSA-7156 (4-2005) (EF 4-2005)

(Over)

6.

WAS ANY RENTAL INCOME (EITHER CASH OR CROP SHARE) INCLUDED IN FIGURING YOUR NET EARNINGS FROM SELF-EMPLOYMENT FOR THIS PERIOD? YES NO IF "YES," ENTER THE AMOUNT OF SUCH INCOME

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 NO

$

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 THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. To find the nearest office, call 1-800-772-1213. Send only comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401.
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 (Month, day, year) SIGN HERE Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route) City and State Zip Code
Enter Name of County (if any) in which you now live

Telephone Number (include area code)

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 Address (Number and street, City, State, & ZIP Code) 2. Signature of Witness Address (Number and street, City, State, & ZIP Code)

Form SSA-7156 (4-2005) (EF 4-2005)