SSA-2854 Statement of Funds You Provide to Another (Original)

Social Security Administration
Refer to:

Office Address:

Phone:

Office Hours:

Dear
We need some information about money you provided to
. 0 He 0 She
has authorized us to contact you concerning any funds you may have provided for 0 his 0 her use. This
information will help us decide if this person is eligible to receive Supplemental Security Income and the amount of
the payments. Your response is voluntary. However, if you do not respond, we may not be able to determine
if 0 he 0 she is entitled to certain payments.
We are authorized to collect the information on the enclosed questionnaire under section 1631 (e) of the Social
Security Act, as amended (42 U.S.C. 1383 (e)). We will not give out any of the information you give us unless we
are required to by law, or unless a Federal or State agency needs the information to decide whether
_ _ _ _ _ _ _ _ _ _ _ _ _ is entitled to some type of benefit. The Federal Register describes other
situations when we might use this information. If you would like information about this, call us at the number listed
above.

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APERWORK REDUCTION ACT:
's information collection meets
arance requirements of 44 U.S.C.
§35 ,
amended by section 2 of the Pape
Reduction Act of 1995. You
t required to answer these
t and Budget control number.
stimate that it will take
e display a valid Office of Manage

Please fill out the attached questionnaire and return it to us in the enclosed postage paid envelope.
Thank you for your cooperation.
Sincerely yours

Manager
Enclosures

Form SSA-2854 112-2000) EF (4-2001)

Form Approved
OMS No. 0960-0481

STATEMENT OF FUNDS YOU PROVIDED TO ANOTHER

The information below refers to: Name of Claimant

1. How much money did you provide to

SSN

2. When did you provide money to the person named above?

$
(MonthfYearl
(Name of individual)
3. Do you expect _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ to pay this money back to you?
(Name of individual)

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

DYes DNo
4. Have you received any payments?
If "yes", when did you receive the first payment? _---,::-:-_-:-:::-:----:-__
D Yes
(MonthfYearl
If "no", when will payments begin?
D No
(MonthfYear)

5. How much are the payments?

6. How often do you receive payments?

$

7. Did _ _ _ _ _ _ _-:-_--:-________ promise to give up any property if he/she does not keep up the payments?
(Name of individual)
D

Yes

D

No

If "yes", what?

8. Are you charging interest?
Yes

D

No

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

9. How much is the interest payment?

10.How often do you receive an interest payment?

$

Remarks:

I know that giving false information on this statement is a crime punishable under Federal and/or State law. All of
the information I have given is true.
Signature

Date

Mailing Address

Telephone Number
(Include area code)

Form SSA-2854 (12-20001 EF (4-2001)