SSA-2574 - Current

Form SSA-2574 (10-2019)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0461

INFORMATION ABOUT JOINT CHECKING/SAVINGS ACCOUNTS
Supplemental Security Income
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 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

• 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• When money is withdrawn, how is it spent?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

None

Form SSA-2574 (10-2019)

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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

Date

Daytime Telephone Number (include Area Code)

Privacy Act Statement
Collection and Use of Personal Information
Sections 1611 and 1631 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information
is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely consideration of your
resources when evaluating eligibility of Supplemental Security Income (SSI) benefits.
We will use the information to determine your original or continued eligibility for SSI benefits. We may also share your information
for the following purposes, called routine uses:
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA)
in the efficient administration of its programs. We will disclose information under this routine use only in situations in which SSA
may enter a contractual or similar agreement with a third party to assist in accomplishing an Agency function relating to this
system of records; and
• 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 Notice (SORN) 60-0103, entitled Supplemental
Security Income Record and Special Veterans Benefits as published in the FR on January 11, 2006, at 71 FR 1830. Additional
information, and a full listing of all our SORNs, is available on our website at www.ssa.gov/privacy.

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.