Form SSA-L2794 Real Prperty Current Market Value Estimate

Form SSA-L2794 (01-2020) UF
Discontinue Prior Editions

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OMB No. 0960-0471

Social Security Administration
Supplemental Security Income

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 (01-2020) UF

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REAL PROPERTY CURRENT
MARKET VALUE ESTIMATE

CLAIMAINT'S NAME

CLAIMANT/RECIPIENT INFORMATION
PART A
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)

PART B

DATE ASSESSMENT ISSUED
(If Available)

ESTIMATE REQUESTED
FROM

TO

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

DATE

Form SSA-L2794 (01-2020) UF

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Privacy Act Statement
Collection and Use of Personal Information

Section 1631 of the Social SecuritySee
Act, Revised
as amended, allows us to collect this information.
Privacy
Act
Furnishing us this information is voluntary. However,
failing to provide all or part of the
Statement
information may prevent us from making an accurate and timely decision on the named
claimant's eligibility for benefits.
We will use the information to determine if the claimant meets requirements for Supplemental
Security Income payments. We may also share your information for the following purposes,
called routine uses:
•

To third party contacts in situations where the party to be contacted has, or is
expected to have, information relating to the individual's capability to manage his/
her affairs or his/her eligibility for or entitlement to benefits under the Social Security
program; and

•

To Federal, State, and local level agencies (or agents on their behalf) for
administering cash or non-cash income or health maintenance programs.

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
(SORN) 60-0089, entitled Claims Folder System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784 and 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 of 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 20 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 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.