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:

Privacy Act Statement See Revised Privacy Act
Statement
Collection of this information is authorized by section 1631(e) of the Social Security
Act, as amended (42 U.S.C. 1383(e)). This
information will help us decide if you are eligible to receive Supplemental Security Income (SSI) and the amount of the
payments. Your response is voluntary, but we cannot decide if you will get SSI payments without it.

We may also use the information you give us when we match records by computer. Matching programs compare our records
with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or
prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not
agree to it.
These and other reasons why information about you may be used or given out are explained in the Federal Register . If you
want to learn more about this, contact any Social Security office.
PAPERWORK REDUCTION ACT STATEMENT

See Revised PRA

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you
are not required to respond to, a collection of information unless it displays a valid OMB control number. We estimate that
it will take you about 5 minutes to complete this form. This includes the time it will take to read the instructions, gather the
necessary facts and fill out the 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 3. When did you receive the money?
to you?
$
4.

(Month/Year)

Do you intend to repay this
money?
Yes
No

If no, stop here. Sign and date the end of
the questionnaire.

6. How much are your payments?
$

7. How often do you
make a payment?

5. Have you started to repay the money?
Yes
When?
(Month/Year)
No
When will
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 (2-1990) EF (7-2000)

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 (OMB) control number. We estimate that it will take about
10 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e)(1)(B) of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to make a determination of eligibility for
Supplemental Security Income and to determine payment amounts.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. However, we may use the information for the administration of
our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0103, entitled Supplemental Security
Income and Special Veterans Benefits. Additional information about this and other system of
records notices and our programs are available online at www.socialsecurity.gov or at your local
Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.