Form SSA-2854 Statement of Funds YOu Provided to Another

Form SSA-2854 (06-2018)
Discontinue Prior Editions
Social Security Administration
Refer to:

Page 1 of 3
OMB No. 0960-0481
Office Address:

Phone:
Office Hours:

Dear

:

We need some information about money you provided to

.
his

has authorized us to contact you concerning any funds you may have provided for

He

She

her use. This 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 to determine if

he

she is entitled to certain payments.

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 (06-2018)

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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?
$
Month/Year (MM/YYYY)

(Name of individual)
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 (MM/YYYY)

No

If "no", when will payments begin?
Month/Year (MM/YYYY)
6. How often do you receive payments?

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

promise to give up any property if he/she does not keep up the
(Name of individual)
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 (MM/DD/YYYY)

Mailing Address

Telephone Number
(include area code)

Form SSA-2854 (06-2018)

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Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) 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 and timely decision on the named individual's eligibility for benefits.
We will use the information you provide to help us determine eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
1. To State agencies to enable those agencies which have elected Federal administration of their
supplementation programs to monitor changes in applicant or recipient income, special needs,
and circumstances; and
2. To State agencies to enable them to assist in the effective and efficient administration of the
Supplemental Security Income program.
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's 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 Notices (SORNs) 60-0089,
entitled Claims Folder and 60-0103, entitled Supplemental Security Income Record and Special Veterans
Benefits. Additional information and a full listing of all our SORNs are available on our website at
https://www.ssa.gov/privacy/sorn.html.

See Revised Privacy Act &
PRA Statements attached
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.