Form SSA-2855 (10-2018)
Discontinue Prior Editions Page 1 of 1
Social Security Administration OMB No. 0960-0481
STATEMENT OF FUNDS YOU RECEIVED
We need information from you about the money you received from:
Information below refers to: Name of Claimant SSN
Name of Person Making Statement if Other Than Claimant Relationship to claimant
1. Name and address of person who gave you money: 2. How much money was given to
you?
3. When did you receive the
money?
4. Do you intend to repay this
money?
Yes
No
If no, stop here. Sign and date
the end of the questionnaire.
5. Have you started to repay the
money?
Yes When?
(Month/Year)
No
When will
you start?
(Month/Year)
6. How much are your payments? 7. How often do you make a payment? 8. Did you promise to give up any property if you do
not keep up your payments?
No Yes
If "yes" what did you promise?
9. What do you plan to use to repay this money? (For example, income from work, SSI, Social Security payments.)
10. Do you now or will you pay interest in the future?
No If "no", stop here. Sign and date the end of the
questionnaire.
Yes If "yes", answer questions 11 and 12.
11. How much interest do you pay? 12. How often do you make
interest payments?
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge.
Signature Date
Mailing address Telephone number
(Include area code)
Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended, allows us to collect information. Furnishing us this information is
voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and timely decision
on your eligibility for Supplemental Security Income (SSI) benefits. We will use the information you provide to determine your
eligibility for SSI benefits. We may also share your information for the following purposes, called routine uses:
1. To State agencies to enable those agencies which have elected to administer their supplementation programs to
monitor changes in applicant or recipient income, special needs, and circumstances; and
2. To State agencies to enable them to assist in the effective and efficient administration of the SSI program.
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 Notices (SORNs) 60-0089, entitled Claims
Folder and 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits. Additional information and a
full listing of all our SORNs are available on our website at https://www.ssa.gov/privacy/sorn.html.
Paperwork Reduction Act-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 10 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.
