Current SSA-2854

Social Security Administration

Refer to:
Office Address:

Phone:
Office Hours:

Dear

:

He
She has
We need some information about money you provided to
.
his
her use. This
authorized us to contact you concerning any funds you may have provided for
information will help us decide if this person is eligible to receive Supplemental Security Income and the
amount of the payments. Your response is voluntary. However, if you do not respond, we may not be able
he
she is entitled to certain payments.
to determine if
We are authorized to collect the information on the enclosed questionnaire under section 1631 (e) of the
Social Security Act, as amended (42 U.S.C. 1383 (e)). We will not give out any of the information you give
us unless we are required to by law, or unless a Federal or State agency needs the information to decide
whether
is entitled to some type of benefit. The Federal Register describes
other situations when we might use this information. If you would like information about this, call us at the
number listed above.
Please fill out the attached questionnaire and return it to us in the enclosed postage paid envelope.
Thank you for your cooperation.
Sincerely yours

Manager
Enclosures

Form SSA-2854 (05-2015) UF (05-2015)
Destroy Prior Editions

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Form Approved
OMB No. 0960-0481

STATEMENT OF FUNDS YOU PROVIDED TO ANOTHER
The information below refers to: Name of Claimant

SSN

1. How much money did you provide to

2. When did you provide money to the person named above?
$

(Name of individual)

(Month/Year)

3. Do you expect

to pay this money back to you?
(Name of individual)

Yes

No

If "no", stop here. Sign and date the end of the questionnaire

4. Have you received any payments?
Yes
If "yes", when did you receive the first payment?
(Month/Year)
No

If "no", when will payments begin?
(Month/Year)

5. How much are the payments?
$
7. Did

6. How often do you receive payments?

promise to give up any property if he/she does not keep up the payments?
(Name of individual)
Yes

If "yes", what?

No
8. Are you charging interest?
Yes
No

If "no", stop here. Sign and date the end of the questionnaire.

9. How much is the interest payment?

10. How often do you receive an interest payment?

$
Remarks:

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

Date

Mailing Address

Telephone Number (include area code)

Form SSA-2854 (05-2015) UF (05-2015)

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Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e)(1)(B) of the Social Security Act, as amended, authorizes us to collect this information. We
will use the information you provide to make a determination of eligibility for Supplemental Security Income
and to determine payment amounts.
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 60-0103, entitled Supplemental Security Income and Special
Veterans Benefits. Additional information about this and other system of records notices and our programs
are 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 (OMB) control number.
We estimate that it will take about 10 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.

Form SSA-2854 (05-2015) UF (05-2015)

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