Form SA-2574 Information About Joint Checking/Savings Accounts

Form Approved
OMB No. 0960-0461

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income

INFORMATION ABOUT JOINT CHECKING/SAVINGS ACCOUNTS
NAME OF APPLICANT/RECIPIENT

SOCIAL SECURITY NUMBER

NAME OF FINANCIAL INSTITUTION

ACCOUNT NUMBER OF JOINT ACCOUNT

PURPOSE: Your name appears with another person(s) as owners of a joint financial institution account. The law requires SSA
to presume that all of the money in the account belongs to you. If you do not agree that all of the money belongs to you, you may
provide evidence on this form about whom the money belongs to.
Please answer these questions about the money in the joint account:
• How much of the money belongs to you? (Check one)

All

Part of it

None

• To whom does the money belong?

• If some of the money belongs to you, how much is yours?

• Why are both names on the account?

• Who makes deposits into the account?

• Who withdraws money from the account?

• When money is withdrawn, how is it spent?

• Other information

Form SSA-2574 (09-2010) EF (07-2012)

Please continue on the other side

STATEMENT OF
RESPONSIBILITY

I understand that the information on this form is subject to verification and I authorize sources to
release to the Social Security Administration information needed to verify my statements.
I know that anyone who knowingly makes or causes to be made a false statement or representation of
material fact in an application or for use in determining a right to payment under the Social Security Act
commits a crime punishable under Federal or State law or both. I affirm that all information I give in
this document or in support of it is true.

Your Signature

Your Social Security Number
(

)

Area Code

YOUR RIGHT
TO PRIVACY

Date

Daytime telephone Number

Section 1631(e) of the Social Security Act (42 U.S.C. 1383(e)), as amended, authorize us to collect this
information. The information you provide will be used to help determine eligibility for Supplemental
Security Income (SSI) payments.
The information you furnish on this form is voluntary. However, failure to provide the requested
information could prevent you or the person who is applying for or receiving SSI payments from an
accurate and timely decision, and could result in the loss of some benefits.
We rarely use the information you supply for any purpose other than for making a determination
relating to approval for SSI payments. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records
(e.g., to the Government Accountability Office and Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity
and improvement of Social Security programs (e.g., to the Bureau of the Census and private
concerns under contract to Social Security).
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies.
Information from these matching programs can be used to establish or verify a person’s eligibility for
Federally-funded or administered benefit programs and for repayment of payments or delinquent debts
under these programs.
A complete list of routine uses for this information is available in our Systems of Records Notices
entitled, Master Beneficiary Record, 60-0090 and Supplemental Security Income Record, 60-0090.
These notices, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.

PAPERWORK
REDUCTION ACT

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 7 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.