Form SSA-L2794 Real Prperty Current Market Value Estimate (revision)

SOCIAL SECURITY ADMINISTRATION
Supplemental Security Income

Form Approved
OMB 0960-0471

Real Property Current Market Value Estimate

Office Hours:
Date:

Dear
The Social Security Administration, administers the supplemental security income (SSI)
program which makes cash payments to people who are aged, blind, or disabled and have only
limited income and assets. To ensure payments are made only to eligible persons, we are
required by law to verify information given to us by applicants and recipients. We sometimes
contact local knowledgeable sources to verify allegations concerning real property values.
Please complete this form, and return it to SSA in the enclosed postage-paid envelope.
Experience has shown that this kind of verification is directly responsible for reducing the
number of incorrect payments to persons whose resources exceed the limit allowed by law. If
you have any questions concerning completion of this form, please feel free to call me at
. Thank you.

SSA Representative

FORM SSA-L2794 (10-2007) (EF 10-2007)

Form Approved
OMB No.0960-0471

REAL PROPERTY CURRENT
MARKET VALUE ESTIMATE

CLAIMANT'S NAME

PAPERWORK/PRIVACY ACT NOTICE: This request is authorized by Section 1631(e) of the Social Security Act as amended (42
U.S.C. 1383(e)). The Social Security Administration needs the information requested on this form to ensure that an individual's
eligibility for benefits is correctly established. Completion of this form is voluntary, however, failure to provide all or part of the
information requested could prevent an accurate and timely decision concerning the individual's eligibility for benefits. The
information you furnish on this form may be disclosed without your consent (1) to comply with Federal laws requiring the release of
information from our records. or (2) to an agency needing this information to decide if the individual is eligible for a health or income
program such as SSI State supplementary payments, food stamps, Medicaid. energy assistance, Veterans benefits railroad
unemployment insurance, or Basic Educational Opportunity Grants. Other disclosures of this information are published in the Federal
See revised
Register; a list is available in local Social Security offices.

Paperwork

Paperwork Reduction Act Statement - This informationReduction
collection meets
the requirements of 44 U.S.C. § 3507, as amended by
Act and
section 2 of the Paperwork Reduction Act of 1995. You
do
not
need
to
answer
these questions unless we display a valid Office of
Privacy Act
Management and Budget control number. We estimate that it will take about 20 minutes to read the instructions, gather the facts,
Statements
and answer the questions. SEND OR BRING THE COMPLETED
FORM below.
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 only comments relating to our time estimate to this address, not the completed form.
PART A
CLAIMANT/RECIPIENT INFORMATION
This section provides important information about the property on which we are requesting a current market value estimate. Note
the time period for which the estimate is requested.
DESCRIPTION OF PROPERTY (include type and size of structures and acreage or lot size)

ADDRESS/LOCATION
CONDITION

CURRENT ASSESSED VALUE
(If Available)

DATE ASSESSMENT ISSUED
(If Available)

ESTIMATE REQUESTED
FROM

TO

PART B
APPRAISER/ESTIMATOR'S INFORMATION
Please complete the identifying information on the first two lines.
Based on the information in Part A and any other information that you may have available (Records of prior sales, current property
sale listings, personal knowledge, etc.) provide an estimate of the property's value.
SIGN AND DATE THE FORM BELOW
NAME (Please Print)

TITLE

ADDRESS

TELEPHONE

ESTIMATED MARKET VALUE FOR PERIOD REQUESTED

(

$

ADDITIONAL REMARKS

SIGNATURE

FORM SSA-L2794 (10-2007) (EF 10-2007)

DATE

)

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 control number. We estimate that it will take about 20
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.

Real Property Current Market Value Estimate, Form SSA-L2794
Privacy Act Statement
Collection and Use of Personal Information

Section 1631(e) of the Social Security Act as amended, [42 U.S.C. 1383(e)] authorizes us
to collect this information. We will use the information you provide to ensure that your
eligibility for benefits is correctly established. The information you provide on this form
is voluntary. However, failure to provide all or part of the requested information could
prevent us from making an accurate and timely decision on your claim.
We rarely use the information you provide on this form for any purpose other than for the
reasons explained above. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency on accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information for Social
Security records (e.g., to the Government Accountability Office, General
Services Administration, National Archives Records Administration, and the
Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State or
local government agencies. Information from these matching agencies can be used to
establish or verify a person’s eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records
Notices entitled Claims Folder System 60-0089 and Supplemental Security Income
Record and Special Veterans Benefits 60-0103. The notices, additional information
regarding this form, and information regarding our system and programs, are available
on-line at www.socialsecurity.gov or at any local Social Security office.