Form SSA-7157-F4 (07-2015) uf (07-2015)
Social Security Administration TOE 420
FORM APPROVED
OMB No. 0960-0064
Farm Arrangement Questionnaire
Section 211(a)(1) of the Social Security Act, as amended, authorizes us to collect this information. We will use the information
you provide to determine if farm rental earnings should be included in your Social Security earnings record. Furnishing us this
information is voluntary. However, failing to provide us with all or part of the information may prevent an accurate and timely
decision on any claim filed. We rarely use the information you supply us for any purpose other than to reconcile Social Security
earnings records. However, we may use the information for the administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the Government Accountability
Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of our
programs (e.g., to the Bureau of the Census and to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act System of
Records Notice 60-0059, entitled, Earnings Record and Self-Employment Income System and 60-0089, entitled, Claims Folder
System. Additional information about these and other system of records notices and our programs is available online at
www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching programs. Matching programs
compare our records with records kept by other Federal, State or local government agencies. We use the information from these
programs to establish or verify a person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
Privacy Act Statement
Collection and Use of Personal Information
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.
Paperwork Reduction Act Statement -
1. Name of Self-Employed Person
2. Social Security No.
From:
To:
3. Period Covered
4. Name and Address of Other Party to Arrangement
5. Family Relationship
(If none, write "None")
6. Description of Arrangement, Agreement, or Understand (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.
