SSA-L2794 (current)

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income

Form Approved
OMB 0960-0471

Real Property Current Market Value Estimate

Office Hours:
Date:

Dear
The Social Security Administration, administers the supplemental security income (SSI)
program which makes cash payments to people who are aged, blind, or disabled and have only
limited income and assets. To ensure payments are made only to eligible persons, we are
required by law to verify information given to us by applicants and recipients. We sometimes
contact local knowledgeable sources to verify allegations concerning real property values.
Please complete this form, and return it to SSA in the enclosed postage-paid envelope.
Experience has shown that this kind of verification is directly responsible for reducing the
number of incorrect payments to persons whose resources exceed the limit allowed by law. If
you have any questions concerning completion of this form, please feel free to call me at
. Thank you.

SSA Representative

FORM SSA-L2794 (08-2010) (EF 08-2010)

Form Approved
OMB No.0960-0471

REAL PROPERTY CURRENT
MARKET VALUE ESTIMATE

CLAIMANT'S NAME

Privacy Act Statement: Collection and Use of Personal Information: Section 1631(e) of the Social Security Act as amended, [42 U.S.C. 1383(e)]
authorizes us to collect this information. We will use the information you provide to ensure that your eligibility for benefits is correctly established.
The information you provide on this form is voluntary. However, failure to provide all or part of the requested information could prevent us from
making an accurate and timely decision on your claim.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above. 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 on 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 for Social
Security records (e.g., to the Government Accountability Office, General Services Administration, National Archives Records Administration, and the
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 of Social Security programs.
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 agencies 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 Claims Folder System 60-0089 and
Supplemental Security Income Record and Special Veterans Benefits 60-0103. The notices, additional information regarding this form, and
information regarding our system and programs, are available on-line at www.socialsecurity.gov or at any local Social Security office.
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 20 minutes to read the instructions, gather the facts, and answer the questions. Send only comments
relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

PART A
CLAIMANT/RECIPIENT INFORMATION
This section provides important information about the property on which we are requesting a current market value estimate. Note
the time period for which the estimate is requested.
DESCRIPTION OF PROPERTY (include type and size of structures and acreage or lot size)

ADDRESS/LOCATION
CONDITION
CURRENT ASSESSED VALUE
(If Available)

DATE ASSESSMENT ISSUED
(If Available)

FROM

ESTIMATE REQUESTED
TO

PART B
APPRAISER/ESTIMATOR'S INFORMATION
Please complete the identifying information on the first two lines.
Based on the information in Part A and any other information that you may have available (Records of prior sales, current property
sale listings, personal knowledge, etc.) provide an estimate of the property's value.
SIGN AND DATE THE FORM BELOW
NAME (Please Print)

TITLE

ADDRESS

TELEPHONE

(
ESTIMATED MARKET VALUE FOR PERIOD REQUESTED

$

ADDITIONAL REMARKS

SIGNATURE

FORM SSA-L2794 (08-2010) (EF 08-2010)

DATE

)