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
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
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)