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 can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-2854 SSA-2854 Form
Form SSA-2855 SSA-2855 Form and Instruction
Justification for Non-Substantive Change 0960-0481.docx Justification for No Material/Nonsubstantive Change
Addendum - 0481 (Final).docx Supplementary Document
Supporting Statement - 0481 (Final).docx Supporting Statement A
SSA-2854 Form
SSA-2855 Form and Instruction

All Historical Document Collections

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

OMB Details

SSA-2854

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form SSA-2854

Statement of Funds YOu Provided to Another

Fillable Printable

Form

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