Non-Substantive Change 0960-0481

Justification for Non-Substantive Changes for Forms SSA-2854 & SSA-2855

Statement of Funds You Provided to Another and Statement of Funds You Received

20 CFR 416.1103(f)

OMB No. 0960-0481

Background

The Social Security Administration (SSA) uses Forms SSA-2854 (Statement of Funds You Provided to Another) and SSA-2855 (Statement of Funds You Received) to verify whether a loan provided to an SSI recipient or deemor is bona fide. Currently, the paper and PDF versions of both forms include a signature requirement.

SSA recently reassessed the need for the respondent’s signature on this form and determined that we no longer require it. Therefore, we are removing the signature requirement from this form. While updating the signatures, we are taking the opportunity to make minor language updates to remove duplicative information and fields and revise for inclusive language.

Revision to the Information Collection

• Change #1: SSA is removing the signature requirement forms SSA-2854 and

SSA-2855. On page 2 of the 2854 and page 1 of the 2855, we are replacing the signature field and instead collecting the name of the person completing the form.

Justification #1: We reassessed the need for a wet signature on this form and determined we no longer require it. Therefore, we will no longer ask respondents to sign this form prior to submitting it to SSA.

• Change #2:  On forms SSA-2854 (page 2) and SSA-2855 (page 1), we are replacing the Penalty of Perjury Statement with the following Penalty of Perjury Warning:

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.

Justification #2:  The Penalty of Perjury Statement is directly connected to the signature and needs to be removed since a signature is no longer required. However, to maintain the intent of that statement, it will be replaced with a Penalty of Perjury Warning.

• Change #3: On the SSA-2854, SSA is making the following minor changes:

  • On page 1, we are removing the second paragraph of the request letter that provides duplicative and truncated Privacy Act information. A complete and recently updated¹ Privacy Act statement is included on page 3.

  • On page 1, we are removing the pronoun selections, opting for gender inclusive pronouns.

  • We are updating the signature line to conform to our current notice standards, listing “Social Security Administration” instead of “Manager.”

  • On page 2 we are removing duplicative “name of individual” fields and modifying the language in question 2, 3, and 7 to refer back to the individual in question 1.

  • On page 2 we are removing gendered pronouns in question 7 and replacing them with gender inclusive pronouns.

Justification #3:

These minor language changes improve clarity of the form, make it easier for respondents to read and complete requested information, and align with administration objectives to make forms more inclusive.

• Change #4: We are revising the PA statements on these forms.

Justification #4: SSA’s Office of the General Counsel conducts systematic reviews of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statements on these forms.

We will implement the new versions of the form upon notification of OMB’s approval.

These actions will not affect the public reporting burden.

1 Updated as of 7/24/2024 OMB renewal; https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202012-0960-011