Form SSA-L2794 Real Prperty Current Market Value Estimate

Form Approved
OMB No. 0960-0471

Social Security Administration
Supplemental Security Income

Real Property Current Market Value Estimate

Office Hours:
Date:

Dear:
The Social Security Administration, administers the supplemental security income (SSI)
program which makes cash payments to people who are aged, blind, or disabled and
have only limited income and assets. To ensure payments are made only to eligible
persons, we are required by law to verify information given to us by applicants and
recipients. We sometimes contact local knowledgeable sources to verify allegations
concerning real property values.
Please complete this form, and return it to SSA in the enclosed postage-paid envelope.
Experience has shown that this kind of verification is directly responsible for reducing
the number of incorrect payments to persons whose resources exceed the limit allowed
by law.
If you have any questions concerning completion of this form, please feel free to call
me at
. Thank you.

SSA Representative

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Form SSA-L2794 (04-2014) EF (04-2014)

Form Approved
OMB No.0960-0471

Social Security Administration

REAL PROPERTY CURRENT
MARKET VALUE ESTIMATE

CLAIMAINT'S NAME

CLAIMANT / RECIPIENT INFORMATION
PART A
This section provides important information about the property on which we are requesting a current market value
estimate. Note the time period for which the estimate is requested.
DESCRIPTION OF PROPERTY (include type and size of structures and acreage or lot size)

ADDRESS / LOCATION
CONDITION

CURRENT ASSESSED VALUE
(If Available)

PART B

DATE ASSESSMENT ISSUED
(If Available)

ESTIMATE REQUESTED
TO

FROM

APPRAISER / ESTIMATOR'S INFORMATION

• Please complete the identifying information on the first two lines.
• Based on the information in Part A and any other information that you may have available (Records of prior
sales, current property sale listings, personal knowledge, etc.) provide an estimate of the property's value.

SIGN AND DATE THE FORM BELOW
NAME (Please Print)

TITLE

ADDRESS

TELEPHONE
(

)

ESTIMATED MARKET VALUE FOR PERIOD REQUESTED $
ADDITIONAL REMARKS

SIGNATURE

DATE

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Form SSA-L2794 (04-2014) EF (04-2014)

Privacy Act Statement
Collection and Use of Personal Information See Revised Privacy Act
Statement Attached
Section 1631 of the Social Security Act, as amended, authorizes us to collect this information.
We will use the information you provide to ensure that your eligibility for benefits is correctly
established.
Furnishing us this information is voluntary. However, failing to provide all or part of the
requested information could prevent us from making a timely decision on your claim.
We rarely use the information you supply for any purpose other than for the reasons explained
above. However, we may use it for the administration and integrity of our programs. We may
also disclose information to another person or to another agency in accordance with approved
routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to
Social Security benefits and/or coverage;
2. 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);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of our programs (e.g., to the Bureau of Census and to
private entities under contract with us).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used 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.
A complete list of routine uses for the information you gave us is available in our Privacy Act
Systems of Records Notices entitled, Claims Folder System, 60-0089, and Supplemental
Security Income Record and Special Veterans Benefits, 60-0103. Additional information about
these and other systems of records notices are available on-line at www.socialsecurity.gov or
at your local Social Security office.
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 control number. We estimate that it will take about 20 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.

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Form SSA-L2794 (04-2014) EF (04-2014)