Form SSA-7104 Partnership Questionnaire

Form Approved
OMB No. 0960-0025

Social Security Administration

PARTNERSHIP QUESTIONNAIRE
(For Determination of Coverage Under Title II of the Social Security Act)
NOTICE - All items must be answered. If you need more space, continue in "REMARKS" section or attach another
sheet. If the Internal Revenue Service has ruled as to whether a partnership exists, please furnish a copy of
the ruling.
NAME OF
FIRM

NAME OF WAGE-EARNER OR
SELF-EMPLOYED PERSON

ADDRESS OF
FIRM

SOCIAL SECURITY NUMBER

EMPLOYER
IDENTIFICATION NUMBER

THIS RELATES TO
THE PERIOD:FROM:

TO:

1. When was the partnership formed?
2. What is the nature of the business?

3. If the partnership agreement is in writing, please submit a copy with this completed form. (Include any changes or new
agreements.) If the partnership agreement is not in writing, give a statement below of the arrangements between the
partners as to their contributions, duties, responsibilities, rights, sharing of profits and losses, and dividing the business
property when the arrangement ends.

4. How much money or other property did each partner
contribute to the business?
5. Were the business books set up to show separate capital accounts for each partner?

yes

no

6. What training and experience for the business does each partner have?

7. What services does each partner perform in connection with the business?

8. How much time does each partner devote to the business?

9. How are the profits or losses divided or shared?

FORM SSA-7104-F3 (02-2015) EF (02-2015)
Destroy prior editions

Page 1

(OVER)

10. Enter below the amount shown as net earnings from self-employment from this business for each partner on the U.S.
partnership return or the individual tax return for the last three years:
NAME OF PARTNER

LAST
YEAR

TELEPHONE NO. SOCIAL SECURITY NO.

TWO YEARS THREE YEARS
AGO
AGO

11. Whose name or names appears on the firm's:
a. truck or automobile licenses?
b. leases?
c. real property?
d. bank account?
e. business licenses and permits?
f. insurance policies?
g. business signs and advertisements?
h. bills?
i. letterheads?
j. orders for merchandise or supplies?
k. business contracts with others?
12. a. Who decides what purchases to make?
b. Who decides what prices to charge?
c. Who decides what repairs or improvements to make?
d. Who decides who to hire and how much to pay them?
e. Who decides when to borrow money for the business?
f. Who decides what advertising to do?
13. a. In what name does the firm file Social Security tax returns for its employees?

b. Who signs the returns?
c. What title does he/she use when signing the returns?
REMARKS - (Use this space for explaining any answers to the questions. If you need more space, attach another sheet.)

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.
SIGNATURE
STREET ADDRESS

TITLE
CITY

FORM SSA-7104-F3 (02-2015) EF (02-2015)

DATE
STATE

Page 2

ZIP CODE

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b)(1) and 205(c)(2)(A) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to make a determination of eligibility for Social
Security benefits. See Revised Privacy Act Statement Attached
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 make a determination
regarding benefits eligibility. 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 60-0089, entitled, Claims Folders System; and, 60-0090,
entitled, Master Beneficiary Record. 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.

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 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. The office is 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.

FORM SSA-7104-F3 (02-2015) EF (02-2015)

Page 3