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

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).

The latest form for Statement of Funds You Provided to Another, Statement of Funds You Received expires 2021-05-31 and can be found here.

SSA-2854

Federal Enterprise Architecture: Income Security - General Retirement and Disability

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