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Ssa-2855
Statement of Funds You Provided to Another, Statement of Funds You Received
OMB: 0960-0481
IC ID: 200252
OMB.report
SSA
OMB 0960-0481
ICR 201111-0960-013
IC 200252
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0481 can be found here:
2021-03-17 - Revision of a currently approved collection
2018-02-19 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form SSA-2855
SSA-2855
Form and Instruction
SSA-2855 Statement of Funds You Recieve
SSA-2855 - Revised Version.pdf
Form and Instruction
SSA-2855 - Current Version.pdf
Current SSA-2855
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
SSA-2855
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 416.1103(f)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
SSA-2855
Statement of Funds You Recieve
SSA-2855 - Revised Version.pdf
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
20,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
20,000
0
0
20,000
0
0
Annual IC Time Burden (Hours)
3,333
0
0
3,333
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Current SSA-2855
SSA-2855 - Current Version.pdf
12/16/2011
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.