Form SSA-2854 Statement of Funds YOu Provided to Another

Form SSA-2854 (XX-20XX)
Discontinue Prior Editions
Social Security Administration

Page 1 of 3
OMB No. 0960-0481

Refer to:

Office Address:

Phone:
Office Hours:

Dear

:

We need some information about money you provided to
They have authorized us to contact you concerning any funds you may have provided for their use. This
information will help us decide if this person is eligible to receive Supplemental Security Income and the
amount of the payments. We will not give out any of the information you give unless we are required to by
law. Your response is voluntary. However, if you do not respond, we may not be able to determine if they
are entitled to certain payments.
Please fill out the attached questionnaire and return it to us in the enclosed postage paid envelope.
Thank you for your cooperation.
Sincerely,

Social Security Administration

Enclosures:

.

Form SSA-2854 (XX-20XX)

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Statement of Funds You Provided to Another
SSN

The information below refers to: Name of Claimant

2. When did you provide money to the person named in
question 1?

1. How much money did you provide to
$
(Name of individual)

Month/Year (MM/YYYY)

3. Do you expect the person named in question 1 to pay this money back to you?
Yes

No If "No", stop here. Sign and date the end of the questionnaire

4. Have you received any payments?
Yes If "yes", when did you receive the first payment?
Month/Year (MM/YYYY)
No

If "no", when will payments begin?
Month/Year (MM/YYYY)

5. How much are the payments?
$

6.

How often do you receive payments?

7. Did the person named in question 1 promise to give up any property if they do not keep up the payments?
Yes If " yes", what?
No
8. Are you charging interest?

Yes

9. How much is the interest payment?
$

No

If "No", stop here. Sign and date the end of the questionnaire
10. How often do you receive an interest payment?

Remarks:

Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in determining a
payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or
continued right to payment, or submits or causes to be submitted any false statement or document knowing the same to contain
any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be
subject to administrative sanctions.
Name of Person Completing the Form

Date (MM/DD/YYYY)

Mailing Address

Telephone Number
(include area code)

Form SSA-2854 (XX-20XX)

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Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended, allows us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part may prevent us from making an accurate
and timely decision in your eligibility for Supplemental Security Income (SSI) benefits.
We will use the information you provide to help us determine eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
• To the following Federal and State agencies to prepare information for verification of benefit
eligibility under section 1631(e) of the Social Security Act: Bureau of Indian Affairs; Office of
Personnel Management; Department of Agriculture; Department of Labor; U.S. Citizenship and
Immigration Services; Internal Revenue Service; Railroad Retirement Board; State Pension Funds;
State Welfare Offices; State Worker's Compensation; Department of Defense; United States Coast
Guard; and Department of Veterans Affairs; and
• To contractors and other Federal Agencies, as necessary, for the purpose of assisting us in the
efficient administration of our programs. We will disclose information under this routine use only in
situations in which we may enter into a contractual or similar agreement to obtain assistance in
accomplishing an SSA function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089,
entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR
58422, and 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits, as
published in the FR on January 11, 2006, at 71 FR 1830. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.

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 15 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.

Replace red highlighted text with new template language dated 10-1-24 attached separately in the document titled "
Privacy Act Statement for SSA-2854 and SSA-2855 OPD 10.1.24"