Current SSA-2854

Form SSA-2854 (09-2024) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 3
OMB No. 0960-0481

Refer to:

Office Address:

Phone:
Office Hours:

Dear

:

We need some information about money you provided to

.

He

She has authorized us to contact you concerning any funds you may have provided for

his

her use. This information will help us decide if this person is eligible to receive

Supplemental Security Income and the amount of the payments. Your response is voluntary. However, if
you do not respond, we may not be able to determine if

he

she is entitled to certain payments.

We are authorized to collect the information on the enclosed questionnaire under section 1631 (e) of the
Social Security Act, as amended (42 U.S.C. 1383 (e)). We will not give out any of the information you give
us unless we are required to by law, or unless a Federal or State agency needs the information to decide
whether
is entitled to some type of benefit. The Federal
Register describes other situations when we might use this information. If you would like information about
this, call us at the number listed above.
Please fill out the attached questionnaire and return it to us in the enclosed postage paid envelope.
Thank you for your cooperation.
Sincerely yours,
Manager

Enclosures:

Form SSA-2854 (09-2024) UF

Page 2 of 3

Statement of Funds You Provided to Another
SSN

The information below refers to: Name of Claimant

2. When did you provide money to the person named above?

1. How much money did you provide to
$
(Name of individual)

Month/Year (MM/YYYY)

3. Do you expect

to pay this money back to you?
(Name of individual)

Yes

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

4. Have you received any payments?
Yes If "yes", when did you receive the first payment?
Month/Year (MM/YYYY)
No

If "no", when will payments begin?
Month/Year (MM/YYYY)

5. How much are the payments?
$
7. Did
payments?

6.

How often do you receive payments?

promise to give up any property if he/she does not keep up the
(Name of individual)

Yes If " yes", what?
No
8. Are you charging interest?

Yes

9. How much is the interest payment?
$

No

If "No", stop here. Sign and date the end of the questionnaire
10. How often do you receive an interest payment?

Remarks:

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 (MM/DD/YYYY)

Mailing Address

Telephone Number
(include area code)

Form SSA-2854 (09-2024) UF

Page 3 of 3

Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended, allows us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part may prevent us from making an accurate
and timely decision in your eligibility for Supplemental Security Income (SSI) benefits.
We will use the information you provide to help us determine eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
• To the following Federal and State agencies to prepare information for verification of benefit
eligibility under section 1631(e) of the Social Security Act: Bureau of Indian Affairs; Office of
Personnel Management; Department of Agriculture; Department of Labor; U.S. Citizenship and
Immigration Services; Internal Revenue Service; Railroad Retirement Board; State Pension Funds;
State Welfare Offices; State Worker's Compensation; Department of Defense; United States Coast
Guard; and Department of Veterans Affairs; and
• To contractors and other Federal Agencies, as necessary, for the purpose of assisting us in the
efficient administration of our programs. We will disclose information under this routine use only in
situations in which we may enter into a contractual or similar agreement to obtain assistance in
accomplishing an SSA function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089,
entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR
58422, and 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits, as
published in the FR on January 11, 2006, at 71 FR 1830. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.

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 15 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.