In accordance with 5 CFR 1320, this information collection is approved.
Inventory as of this Action
Requested
Previously Approved
07/31/2027
07/31/2027
07/31/2027
40,000
0
40,000
46,000
0
46,000
0
0
0
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.
US Code:
42 USC 1382
Name of Law: Social Security Act
US Code:
42 USC 1383
Name of Law: Social Security Act
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.
Form SSA-2854 SSA-2854
Justification for Non-Substantive Change 0960-0481.docx
SSA-2854