Current SSA-2854

Social Security Administration

Refer to:
Office Address:

Phone:
Office Hours:
Dear

:

We need some information about money you provided to
.
He
She
has authorized us to contact you concerning any funds you may have provided for
his
her use. This
information will help us decide a Social Security matter. Your response is voluntary. However, if you do
not respond, we may not be able to determine if
he
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.

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 (11-2011) EF (11-2011)

Form Approved
OMB No. 0960-0481

STATEMENT OF FUNDS YOU PROVIDED TO ANOTHER
The information below refers to: Name of Claimant

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

1. How much money did you provide to
$
(Name of individual)
3. Do you expect
you?

to pay this money back to
(Name of individual)

4. Have you received any payments?
Yes If "yes", when did you receive the first payment?
No

If "no", when will payments begin?

5. How much are the payments?

(Month/Year)

(Month/Year)
6. How often do you receive payments?

$
7. Did
payments?

promise to give up any property if he/she does not keep up the
(Name of individual)

Yes

If "yes", what?

8. Are you charging interest?
Yes
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 (11-2011) EF (11-2011)

Form Approved
OMB No. 0960-0481

Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended, authorizes us to collect this information. The information you
prov ide will be used to determine eligibility to receive Supplemental Security Income (SSI) and the amount of the
payments for the individual to which you provided funds.
The information you furnish on this form is voluntary. However, failure to provide the requested information will prevent
us from making a determination of eligibility for SSI.
We rarely use the information you supply for any purpose other than for determining eligibility. However, we may use it
for the administration and integrity of Social Security programs. We may also disclose information to another person or
to another agency in accordance with approved routine uses, which include but are not limited to thef ollowing:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or
coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, state and
local level; and
4. To facilitate statistical research, audit or investigative activities necessary to assure the integrity of Social Security
programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records
with records kept by other Federal, state or local government agencies. Information from these matching programs can
be used to establish or verify a person’s eligibility for Federally funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs. Additional information regarding this form, routine
uses of information, and our programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.

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 control number. We estimate that it will take about 10 minutes to read
the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory
or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send
only comments relating to our time estimate to this address, not the completed form.

Form SSA-2854 (11-2011) EF (11-2011)