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Agency Information Collection Activities: Comment Request

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The Social Security Administration (SSA) publishes a list of information collection packages requiring clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes a revision of an OMB-approved information collection.

SSA is soliciting comments on the accuracy of the agency's burden estimate; the need for the information; its practical utility; ways to enhance its quality, utility, and clarity; and ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Mail, email, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and SSA Reports Clearance Officer at the following addresses or fax numbers.

(OMB) Office of Management and Budget, Attn: Desk Officer for SSA, Fax: 202-395-6974, Email address:

(SSA) Social Security Administration, OLCA, Attn: Reports Clearance Director, 3100 West High Rise, 6401 Security Blvd., Baltimore, MD 21235, Fax: 410-966-2830, Email address:

Or you may submit your comments online through, referencing Docket ID Number [SSA-2014-0079].

SSA submitted the information collection below to OMB for clearance. Your comments regarding the information collection would be most useful if OMB and SSA receive them 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than January 21, 2015. Individuals can obtain copies of the OMB clearance package by writing to

Statement of Funds You Provided to Another and Statement of Funds You Received—20 CFR 416.1103(f)—0960-0481. SSA uses Forms SSA-2854 (Statement of Funds You Provided to Another) and SSA-2855 (Statement of Funds You Received) to gather information to verify if a loan is bona fide for Supplemental Security Income (SSI) recipients. Form SSA-2854 asks the lender for details on the transaction, and Form SSA-2855 asks the borrower the same basic questions independently. Agency personnel then compare the two statements, gather evidence if needed, and make a decision on the validity of the bona fide status of the loan.

For SSI purposes, we consider a loan bona fide if it meets these requirements:

  • Must be between a borrower and lender with the understanding that the borrower has an obligation to repay the money;
  • Must be in effect at the time the cash goes to the borrower, that is, the agreement cannot come after the cash is paid; and
  • Must be enforceable under State law, often there are additional requirements from the State.

SSA collects this information at the time of initial application for SSI or at any point when an individual alleges being party to an informal loan while receiving SSI. SSA collects information on the informal loan through both interviews and mailed forms. The agency's field personnel conduct the interviews and mail the form(s) for completion, as needed. The respondents are SSI recipients and applicants, and individuals who lend money to them.

Type of Request: Revision of an OMB-approved information collection.

Modality of collectionNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)
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Dated: December 17, 2014.

Faye Lipsky,

Reports Clearance Director, Social Security Administration.

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[FR Doc. 2014-29821 Filed 12-19-14; 8:45 am]