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
her use. This
has authorized us to contact you concerning any funds you may have provided for
his
information will help us decide if this person is eligible to receive Supplemental Security Income and the amount of
the payments. 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.
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C.
§3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these
questions unless we display a valid Office of Management and Budget control number. We estimate that it will take
you about 10 minutes to read the instructions, gather the necessary facts, and answer the questions.
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 (12-2000) EF (4-2001)

Form Approved
OMB No. 0960-0481

STATEMENT OF FUNDS YOU PROVIDED TO ANOTHER
SSN

The information below refers to: Name of Claimant

1. How much money did you provide to

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

(Month/Year)

(Name of individual)
3. Do you expect
Yes

No

to pay this money back to you?

(Name of individual)
If "no", stop here. Sign and date the end of the questionnaire.

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

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

If "yes", what?

No
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 (12-2000) EF (4-2001)