Information Collection

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

IC 9375 under ICR 200811-0960-006 · OMB 0960-0481.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0481 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-2855 Statement of Funds You Provided to Another, Statement of Funds You Received	Form
SSA-2855 Statement of Funds You Received SSA 2855 revised.pdf	Form
SSA-2854 Statement of Funds You Provided To Another SSA 2854 Mark-Up revised.pdf	Form
Original SSA-2854.pdf SSA-2854 Statement of Funds You Provide to Another (Original)	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1103(f)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-2855	Statement of Funds You Received	SSA 2855 revised.pdf		No		Paper Only
Form	SSA-2854	Statement of Funds You Provided To Another	SSA 2854 Mark-Up revised.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	40,000	40,000
Annual IC Time Burden (Hours)	6,667	6,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-2854 Statement of Funds You Provide to Another (Original)	Original SSA-2854.pdf	04/29/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.