Form SSA-2855 Statement of Funds You Recieve

Form SSA-2855 (XX-XXXX)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0481

STATEMENT OF FUNDS YOU RECEIVED
We need information from you about the money you received from:
Information below refers to: Name of Claimant

SSN

Name of Person Making Statement if Other Than Claimant

Relationship to claimant

1. Name and address of person who gave you money:

2. How much money was given to 3. When did you receive the
you?
money?

4. Do you intend to repay this
money?
Yes

No

5. Have you started to repay the
money?
Yes

When?
(MM/YYYY)

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

No

When will
you start?

(MM/YYYY)
6. How much are your payments? 7. How often do you make a payment? 8. Did you promise to give up any property if you do
not keep up your payments?
No
Yes

If "yes" what did you promise?
9. What do you plan to use to repay this money? (For example, income from work, SSI, Social Security payments.)

10. Do you now or will you pay interest in the future?
No If "no", stop here. Sign and date the end of the
questionnaire.

11. How much interest do you pay? 12. How often do you make
interest payments?

Yes If "yes", answer questions 11 and 12.
Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in determining a
payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or
continued right to payment, or submits or causes to be submitted any false statement or document knowing the same to contain
any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be
subject to administrative sanctions.
Name of person completing the form
Date

Mailing address

Telephone number
(Include area code)

Form SSA-2855 (XX-XXXX)

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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 may prevent us from making an accurate and timely
decision in your eligibility for Supplemental Security Income (SSI) 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:
• To the following Federal and State agencies to prepare information for verification of benefit eligibility under
section 1631(e) of the Social Security Act: Bureau of Indian Affairs; Office of Personnel Management;
Department of Agriculture; Department of Labor; U.S. Citizenship and Immigration Services; Internal Revenue
Service; Railroad Retirement Board; State Pension Funds; State Welfare Offices; State Worker's Compensation;
Department of Defense; United States Coast Guard; and Department of Veterans Affairs; and
• To contractors and other Federal Agencies, as necessary, for the purpose of assisting us in the efficient
administration of our programs. We will disclose information under this routine use only in situations in which we
may enter into a contractual or similar agreement to obtain assistance in accomplishing an SSA function relating
to this system of records.
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) 60-0089, entitled
Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422, 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.
Replace red highlighted text with new template language dated
10-1-24 attached separately in the document titled "Privacy Act
Statement for SSA-2854 and SSA-2855 OPD 10.1.24"
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 15 minutes to read the instructions, gather the
facts, and answer the questions. Send only comments regarding this burden estimate or any other aspect of
this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401.