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 (08-2010) (EF 08-2010)

Form Approved
OMB No.0960-0471

REAL PROPERTY CURRENT
MARKET VALUE ESTIMATE

CLAIMANT'S NAME

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.
See Revised Privacy Act
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
Statement
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.

See Revised Paperwork
Reduction
Act § 3507, as amended by section 2 of the
- This information collection meets the requirements
of 44 U.S.C.

Paperwork Reduction Act Statement
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.

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)

FROM

ESTIMATE REQUESTED
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 (08-2010) (EF 08-2010)

DATE

)

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 1631 of the Social Security Act, as amended, authorizes us to collect this information.
We will use the information you provide to ensure that your eligibility for benefits is correctly
established.
Furnishing us this information is voluntary. However, failing to provide all or part of the
requested information could prevent us from making a timely decision on your claim.
We rarely use the information you supply for any purpose other than for the reasons explained
above. However, we may use it for the administration and integrity of our programs. We may
also disclose information to another person or to another agency in 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 us in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and 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 and improvement of our programs (e.g., to the Bureau of Census and to
private entities under contract with us).
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 programs can be used to establish or verify a person's
eligibility for federally-funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
A complete list of routine uses for the information you gave us is available in our Privacy Act
Systems of Records Notices entitled, Claims Folder System, 60-0089, and Supplemental Security
Income Record and Special Veterans Benefits, 60-0103. Additional information about these and
other systems of records notices are available on-line at www.socialsecurity.gov or at your local
Social Security office.

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 (OMB) 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 21235-0001.