Statement of Funds You Provided to Another, Statement of Funds You Received

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-2854 Statement of Funds YOu Provided to Another	Form	Modified	Repair queued
Form SSA-2854 SSA-2854	Form	Modified	Repair queued
Form SSA-2855 Statement of Funds You Recieve	Form and Instruction	Modified	Available
Form SSA-2855 SSA-2855	Form and Instruction	Modified	Repair queued
Addendum - 0481 (Final).docx	Supplementary Document	Uploaded 2021-03-16	Available
Supporting Statement - 0481 (Final).docx	Supporting Statement A	Uploaded 2021-03-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9375	SSA-2854	Form	Modified	Statement of Funds YOu Provided to Another
9375	SSA-2854	Form	Modified
9375	SSA-2854	Other-Revised PA & PRA Statements	Modified
200252	SSA-2855	Form and Instruction	Modified	Statement of Funds You Recieve
200252	SSA-2855	Form and Instruction	Modified
200252	SSA-2855	Other-Revised PA & PRA Statements	Modified

ICR Details

OMB Control No: 0960-0481	ICR Reference No: 202012-0960-011
Status: Historical Active	Previous ICR Reference No: 201711-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Funds You Provided to Another, Statement of Funds You Received
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/24/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/17/2021
Terms of Clearance: The agency made clarifying edits in the Supporting Statement A to the description of the information collection. The agency also revised the burden table in ROCIS.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	36 Months From Approved	07/31/2024
Responses	40,000	0	40,000
Time Burden (Hours)	46,000	0	6,666
Cost Burden (Dollars)	0	0	0

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Abstract: Forms SSA-2854 and SSA-2855 collects information where the SSI beneficiary alleges that he or she borrowed funds informally from non-commercial lender, e.g. a relative or friend. The borrower/beneficiary and the lender of the funds complete these statements. Forms SSA-2854 and SSA-2855 are required to determine whether the proceeds from the transaction are income to the borrower. If the transaction constitutes a bona fide loan, then the proceeds are not income to the borrower. Form SSA-2855 (Statement of Funds You Received) requests information from the SSI applicant/beneficiary by personal interview. Form SSA-2854 (Statement of Funds You Provided to Another) requests information by mail from the other party to the transaction. The respondents are SSI beneficiaries who informally borrow money and those persons who lend the funds (who may or may not be SSI beneficiaries).

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Authorizing Statute(s): US Code: 42 USC 1382 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 667	01/06/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 14170	03/12/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
SSA-2854	SSA-2854	Statement of Funds YOu Provided to Another
SSA-2855	SSA-2855	Statement of Funds You Recieve

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	40,000	40,000	0	0	0	0
Annual Time Burden (Hours)	46,000	6,666	0	0	39,334	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: When we last cleared this IC in 2018, the burden was 6,666 hours. However, we are currently reporting a burden of 10,000 hours. This change stems from an increase in the completion time from 10 minutes to 15 minutes. This change is supported by our current management information data. Note: The total burden reflected in ROCIS is 46,000, while the burden cited in #12 of the Supporting Statement is 10,000. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, one-way, drive burden. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

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Annual Cost to Federal Government: $729,127

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/17/2021

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