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Ssa-2854
Statement of Funds You Provided to Another, Statement of Funds You Received
OMB: 0960-0481
IC ID: 9375
OMB.report
SSA
OMB 0960-0481
ICR 202410-0960-017
IC 9375
( )
Documents and Forms
Document Name
Document Type
Form SSA-2854
SSA-2854
Form
SSA-2854 Statement of Funds YOu Provided to Another
SSA-2854 (revised).pdf
Form
SSA-2854 (current).pdf
Current SSA-2854
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
SSA-2854
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 416.1103(f)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
SSA-2854
Statement of Funds YOu Provided to Another
SSA-2854 (revised).pdf
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
20,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
20,000
0
0
0
0
20,000
Annual IC Time Burden (Hours)
23,000
0
0
0
0
23,000
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Current SSA-2854
SSA-2854 (current).pdf
10/23/2024
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.