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Federal forms, ICRs, and supporting documents

Information Collection Request

Statement of Funds You Provided to Another, Statement of Funds You Received 20 CFR 416.1103(f)

ICR 200604-0960-004 · OMB 0960-0481 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
9375 Statement of Funds You Provided to Another, Statement of Funds You Received 20 CFR 416.1103(f) Form Migrated
ICR Details
0960-0481 200604-0960-004
Historical Active 200303-0960-008
SSA
Statement of Funds You Provided to Another, Statement of Funds You Received 20 CFR 416.1103(f)
Extension without change of a currently approved collection   No
Regular
Approved without change 06/05/2006
Retrieve Notice of Action (NOA) 04/13/2006
  Inventory as of this Action Requested Previously Approved
06/30/2009 06/30/2009 06/30/2006
40,000 0 40,000
6,667 0 6,667
0 0 0
Forms SSA-2854 and SSA-2855 are used to collect information in situations where the SSI beneficiary alleges that he or she borrowed funds informally from a non-commercial lender, e.g., a relative or a friend. The statements 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. The respondents are the borrower/beneficiary and the lender of the funds.
None
None
No
1
IC Title Form No. Form Name
Statement of Funds You Provided to Another, Statement of Funds You Received 20 CFR 416.1103(f) SSA-2854, SSA-2855
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 40,000 40,000 0 0 0 0
Annual Time Burden (Hours) 6,667 6,667 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/13/2006