Form SA-2574 Information About Joint Checking/Savings Accounts

Form Approved
OM6 No. 0960-0461

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income

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INFORMATION ABOUT JOINT CHECKINGISAVINGS ACCOUNTS
NAME OF APPLICANTIRECIPIENT

SOCIAL SECURITY NUMBER

NAME OF FINANCIAL INSTITUTION

ACCOUNT NUMBER OF JOINT ACCOUNT

PURPOSE: Your name appears with another person(s) as owners of a joint financial institution account. The
law requires SSA to presume that all of the money in the account belongs to you. If you do not agree that all
of the money belongs to you, you may provide evidence on this form about whom the money belongs to.
Please answer these questions about the money in the joint account:
How much of the money belongs to you? (Check one)
All

Part of it

None

To whom does the money belong?

If some of the money belongs to you, how much is yours?

Why are both names on the account?

Who makes deposits into the account?

Who withdraws money from the account?

When money is withdrawn, how is it spent?

Other information

Form SSA-2574 (2-1998) EF (8-2000)

Please continue on the other side

STATEMENT OF
RESPONSIBILITY

I understand that the information on this form is subject t o verification and I
authorize sources t o release t o the Social Security Administration information
needed t o verify m y statements.
I know that anyone w h o knowingly makes or causes t o be made a false statement
or representation of material fact i n an application or for use in determining a right
t o payment under the Social Security A c t commits a crime punishable under Federal
or State law or both. I affirm that all information I give in this document or i n
support of it is true.

Your Signature

Your Social Security Number
(

1

Area Code
YOUR RIGHT
TO PRIVACY

Date

Daytime telephone Number

We are authorized t o collect the information on this form under Section 1631 (e) of
the Social Security Act, as amended (42 U.S.C. 1383(e)). Giving us the information
on this form is voluntary. You do not have t o do it, but you or the person who is
applying for or receiving SSI benefits cannot get them unless you give us this
information.
We will use the information on this form t o help decide eligibility for SSI payments.
Sometimes the law requires us t o give out the facts o n this form without your
consent. We will release this information t o another person or Government agency
if Federal law requires that w e do so or t o do the research and audits needed t o
administer or improve Social Security programs. We might also release the
information if Social Security or another agency needs the information t o decide
eligibility for benefits or for a health or income program such as SSI state
supplementary payments, food stamps, Medicaid, etc.
These and other reasons w h y information about you may be used or given out are
explained i n the Federal Register. If you would like more information about this, get
in touch w i t h any Social Security office.

Thefollowing revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 8 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 control number. We estimate that it will take about 7
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send&o comments relating to our time estimate to this
address, not the completedform.