Current SSA-2855

Form Approved
OMB No. 0960-0481

STATEMENT OF FUNDS YOU RECEIVED
We need information from you about the money you received from:

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.
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)