Form SSA-2855 Statement of Funds You Recieve

Form Approved
OMB No. 0960-0481

STATEMENT OF FUNDS YOU RECEIVED
We need information from you about the money you received from:
See Revised Privacy Act Statement Attached

Privacy Act Statement

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.
See Revised PRA Statement Attached
Information below refers to: Name of Claimant

SSN

Name of Person Making Statement if Other Than Claimant

Relationship to Claimant

1.

Name and address of person who gave you money

2. How much money was given
to you?

3.

When did you receive the money?

(Month/Year)

$
4.

6.

How much are your payments?

7.

How often do you
make a payment?

Do you intend to repay this
5. Have you started to repay the money?
money?
Yes
When?
Yes
No
(Month/Year)
If no, stop here. Sign and date the end
No
When will
of
you start?
(Month/Year)
8. Did you promise to give up any property if you do not keep up your payments?
No
Yes
If "yes", what did you promise?

$

9.

What do you plan to use to repay this money? (For example, income from work, SSI, Social Security payments.)

10. Do you now pay interest or will you pay interest in the future?
No
If "no", stop here. Sign and date the end of the questionnaire.
Yes If "yes", answer questions 11 and 12.
11. How much interest do you pay?

12. How often do you make interest payments?

$
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-2855

(11-2011) EF (11-2011)

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Privacy Act Statement

Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended, authorizes us to collect the information
on this form. We will use the information you provide to determine your eligibility to receive
Supplemental Security Income (SSI).
Your response is voluntary. However, failure to provide us with this information will prevent an
accurate and timely decision on your SSI eligibility determination.
We rarely use the information you provide for any purpose other than to determine SSI
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 the following:
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 make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level;
3. To comply with Federal laws requiring the disclosure of the information from our
records; and,
4. To facilitate statistical research, audit or investigative activities necessary to assure
the integrity of SSA programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with those of other Federal, State, or local government agencies.
We can use information from these matching programs 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.
A complete list of routine uses for this information is available in our System of Records Notices
entitled, Supplemental Security Income Record and Special Veterans Benefits, 60-0103, and
Claims Folders Systems, 60-0089. This notice, additional information regarding this form, and
information regarding our programs and systems, are available on-line at
http://www.socialsecurity.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. SED OR BRIG THE COMPLETED FORM TO

YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (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.