Form SSA-2855 Statement of Funds You Recieve

Form SSA-2855 (08-2016)
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Social Security Administration

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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
Section 1631(e)(1)(B) of the Social Security Act, as amended, authorizes us to collect
this information.
Statement
AttachedWe 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.
Paperwork Reduction Act -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.
Information below refers to: Name of Claimant
SSN
Name of Person Making Statement if Other Than Claimant
1. Name and address of person who gave you money:

Relationship to claimant
2. How much money was given to 3. When did you receive the
you?
money?
4. Do you intend to repay this
money?
Yes

No

5. Have you started to repay the
money?
Yes When?
(Month/Year)

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

No When will

you start?

(Month/Year)
6. How much are your payments? 7. How often do you make a payment? 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 or will you pay interest in the future?
No If "no", stop here. Sign and date the end of the
questionnaire.

11. How much interest do you pay? 12. How often do you make
interest payments?

Yes If "yes", answer questions 11 and 12.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge.
Signature
Date
Mailing address

Telephone number
(Include area code)