Fillable Ssa-7160 Employment Relationship Questionnaire

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Ssa-7160 Employment Relationship Questionnaire

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SOCIAL SECURITY ADMINISTRATION
EMPLOYMENT RELATIONSHIP QUESTIONNAIRE
Form Approved
OMB No. 0960-0040
FIRM'S NAME
ADDRESS OF FIRM
FIRM'S FEDERAL EMPLOYER'S IDENTIFICATION
WORKER'S NAME
WORKER'S SOCIAL SECURITY NUMBER
DATE WORKER'S SERVICES PERFORMED
FROM TO
Note - The term "worker" refers to the person who performed the services.
The term "firm" refers to the individual, corporation, partnership, association, or other type of organization for
whom the services were performed.
Check type of firm:
Individual Partnership Corporation Other (specify)
1. Give nature of firm's business (for example drugstore, home owner, radio manufacturer, farmer, etc.);
2. State worker's occupation or title and give a complete description of the work done by him/her.
3. (a) If the work was done under a written agreement or contract, please attach a copy.
(b) If the agreement was not in writing, describe the terms and conditions of the work arrangement.
(c) If the actual working arrangement differed in any way from the agreement explain the differences, why they
occurred and the date or dates of such change.
4. (a) Was the worker given training in the work by the firm?
If "Yes," how often and what kind?
Yes No
(b) Was the worker required to follow daily, weekly, etc., routines or schedules
established by the firm? If "Yes," explain the nature of the instructions.
Yes No
(c) Was the worker given instructions about the way the work was to be done?
If "Yes," explain the nature of the instructions.
Yes No
(d) Could the firm change the methods used by the worker in doing the work, or
otherwise direct him/her as to how to do the work?
Explain your answer
Yes No
Form SSA-7160 (01-2019) UF
Discontinue Prior Editions
Page 1 of 5
5. (a) Did the firm engage the worker:
Full-time Part-time Particular job Indefinite period
Other (please explain)
(b) Did the firm require the worker to work during fixed hours or at certain times?
If "Yes," explain.
Yes No
6. Name the months and number of days worked in each month during this period of employment.
7. (a) State the kind and value of tools and equipment furnished by: the firm
the worker
(b) List any other expense connected with the work that the worker had:
8. Was it agreed or understood that the worker would perform the services personally?
If "No," explain
Yes No
9. (a) Did the worker have helpers?
Yes No
(b) Were the helpers hired by:
The worker? The firm?
If hired by the workers, was the firm's consent and approval necessary? Yes No
Who could discharge the helpers:
The worker? The firm?
(c) Who paid the helpers:
The worker? The firm?
If the worker paid the helpers, did the firm repay him/her? Yes No
(d) How much of the work did the helpers do?
10. Who owned or rented the premises where the work was done?
11. (a) Check the type of pay worker received:
Salary Commission
Hourly
Wage
Advance
or draw
Other (please explain)
(b) Was he/she guaranteed a minimum pay?
Yes No
12. Was the worker eligible for a pension, bonuses, paid vacations, sick pay, etc?
If "Yes," explain
Yes No
13.
Did the firm carry workmen's compensation insurance on the worker?
Yes No
14.
Were social security taxes deducted from amounts paid the workers?
Yes No Unknown
15. How did the worker report his/her earnings for income tax purposes?
Wages Self-employment income Unknown
16. (a) Was the worker permitted to work for others if such work would not interfere with the services for the firm?
If "Yes," answer (b).
Yes No
(b) describe any work he/she did for others:
Page 2 of 5
Form SSA-7160 (01-2019) UF
17.
(a) Could the firm discharge the worker at any time?
Yes No
(b) Could the worker quit at any time?
Yes No
(c) Would liability be incurred if the worker quit or was
discharged before the job was completed? If "Yes," explain
Yes No
18.
(a) Did the worker work under:
His/her own business name? The firm's name?
(b) Did the worker advertise or maintain a business listing in the telephone directory?
Yes No
(c) Did the worker hold himself/herself out to the public as available to do work of this nature?
Yes No
Of any other nature? If "Yes," explain
(d) Did the worker have a shop or office of his/her own? If "Yes," where?
Yes No
(e) Was a license or certificate needed for the work? If "Yes," what kind?
Yes No
19. Please explain in detail why you believe the worker was an employee of the firm or was an independent
contractor.
20.
Has any other governmental agency ruled on the status of services performed by the worker or another person
performing the same or similar services?
Yes No
21. ANSWER NO. 21 ONLY IF WORKER WAS AN AGENT-DRIVER OR COMMISSION-DRIVER
(a) List the products and/or services distributed (for example, bakery products, laundry services):
(b) If the worker distributed more than one product or service, which was considered the principal or main
product?
Explain
(c) Did the worker serve:
Customers or routes designated by the firm?
The worker? Both
22.
ANSWER NOS. 22 AND 23 ONLY IF THE WORKER WAS A LIFE INSURANCE SALESMAN
Did the worker devote his/her entire or principal working time to the sale of life
or annuity contracts for the firm?
Yes No
Page 3 of 5
Form SSA-7160 (01-2019) UF
23.
(a) Under the terms of the original contact, was it agreed that the worker would work:
Full-time Part-time
Other (please explain)
(b) Were these terms of the contract ever changed?
If "Yes," give the date and explain the changes
Yes No
(c) Were the changes agreed upon by both the firm and the worker?
Yes No
24.
ANSWER NO. 24 ONLY IF THE WORKER WAS A HOME WORKER
(a) Who furnished materials or goods used by the worker?
Worker Firm
Was the worker furnished a pattern of given instructions to follow in making
the product?
Yes No
Explain
(b) Was the worker required to return the finished product either to the firm
or to someone designated by the firm?
Yes No
25.
ANSWER NOS. 25, 26, 27, AND 28 ONLY IF THE WORKER WAS A TRAVELING OR CITY SALESMAN
Did the worker have an exclusive territory?
Yes No
Did the firm specify when and how often to work the territory?
If "Yes," explain
Yes No
26.
(a) What percent of his/her total sales for the firm were made to wholesalers, retailers,
contractors, or operators of hotels, restaurants, or other similar establishments?
%
What percent of his/her total working time was spent in making such sales?
%
(b) What percent of his/her working time for the firm was spent in selling to organizations
other than those specified in (a), such as manufacturers, schools, churches?
%
27.
What was the approximate number of hours worked per day for the firm?
Hours
28.
Was the worker required to forward the orders to the firm?
Yes No
REMARKS: (This space may be used for additional explanation)
I CERTIFY that all copies of contracts and all statements submitted herewith are true, correct, and complete to
the best of my knowledge and belief.
SIGNATURE TITLE
ADDRESS DATE
Page 4 of 5
Form SSA-7160 (01-2019) UF
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information
may prevent us from making an accurate decision on the worker’s claim.
We will use the information you provide to determine eligibility for benefits. We may also share
the information for the following purposes, called routine uses:
• To third party contacts where necessary to establish or verify information provided by
representative payees or payee applicants; and
• To employers or former employers for correcting or reconstructing earnings records
and for Social Security tax purposes only.
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’ 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) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784. Additional information, and a full listing of all 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
25 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 (TTY1-800-325-0778). 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.
Page 5 of 5
Form SSA-7160 (01-2019) UF
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Ssa-7160 Employment Relationship Questionnaire

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Completed 3 November 2019

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