Form SSA-L2794 Real Prperty Current Market Value Estimate (revision)

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income

Form Approved
OMB 0960-0471

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 (8-1989) (EF 8-2000)

Form Approved
OMB No.0960-0471

REAL PROPERTY CURRENT
MARKET VALUE ESTIMATE

CLAIMANT'S NAME

PAPERWORK/PRIVACY ACT NOTICE: This request is authorized by Section 1631(e) of the Social Security Act as amended (42
U.S.C. 1383(e)). The Social Security Administration needs the information requested on this form to ensure that an individual's
eligibility for benefits is correctly established. Completion of this form is voluntary, however, failure to provide all or part of the
information requested could prevent an accurate and timely decision concerning the individual's eligibility for benefits. The
information you furnish on this form may be disclosed without your consent (1) to comply with Federal laws requiring the release of
information from our records. or (2) to an agency needing this information to decide if the individual is eligible for a health or income
program such as SSI State supplementary payments, food stamps, Medicaid. energy assistance, Veterans benefits railroad
unemployment insurance, or Basic Educational Opportunity Grants. Other disclosures of this information are published in the Federal
Register; a list is available in local Social Security offices.
PAPERWORK REDUCTION ACT STATEMENT: The Paperwork Reduction Act of 1995 requires us to notify you that this information
collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not
conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control
number. We estimate that it will take you about 20 minutes to complete this form. This includes the time it will take to read the
instructions, gather the necessary facts and fill out the form.
PART A
CLAIMANT/RECIPIENT INFORMATION
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)

DATE ASSESSMENT ISSUED
(If Available)

ESTIMATE REQUESTED
FROM

TO

PART B
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

FORM SSA-L2794 (8-1989) (EF 8-2000)

DATE

)