OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 0960-0481 · SSA.

OMB 0960-0481

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). We are submitting this non-substantive change request to remove the signature requirement, replacing the Penalty of Perjury Statemenwith with a Penalty of Perjury Warning Statement, making minor changes to the language on the form for clarity, and revising the Privacy Act Statement.

The latest form for Statement of Funds You Provided to Another, Statement of Funds You Received expires 2027-07-31 and is listed under ICR 202410-0960-017.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form SSA-2854 Statement of Funds YOu Provided to AnotherForm
Form SSA-2855 Statement of Funds You RecieveForm and Instruction
Justification for Non-Substantive Change 0960-0481.docxJustification for No Material/Nonsubstantive Change
Addendum - 0481 (Final).docxSupplementary Document
Supporting Statement - 0481 (Final).docxSupporting Statement A
SSA-2854 Form
SSA-2855 Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202410-0960-017 No material or nonsubstantive change to a currently approved collection 2024-10-23 Approved without change
202012-0960-011 Revision of a currently approved collection 2021-03-17 Approved with change
201711-0960-002 Revision of a currently approved collection 2018-02-19 Approved without change
201410-0960-001 Revision of a currently approved collection 2015-01-12 Approved without change
201111-0960-013 Revision of a currently approved collection 2012-03-26 Approved without change
200811-0960-006 Revision of a currently approved collection 2009-04-30 Approved without change
200604-0960-004 Extension without change of a currently approved collection 2006-04-13 Approved without change
200303-0960-008 Extension without change of a currently approved collection 2003-03-24 Approved without change
200002-0960-008 Extension without change of a currently approved collection 2000-02-10 Approved without change
199701-0960-001 Extension without change of a currently approved collection 1997-01-27 Approved without change
199311-0960-006 Extension without change of a currently approved collection 1993-11-24 Approved without change
199008-0960-009 Extension without change of a currently approved collection 1990-08-30 Approved without change
198908-0960-008 New collection (Request for a new OMB Control Number) 1989-08-07 Approved without change

OMB Details

SSA-2854

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Information collection instruments
FormNameElectronic accessType
Form SSA-2854Statement of Funds YOu Provided to AnotherFillable PrintableForm

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.