Support Statement NOV 2006

November 2006

Support Statement for Forms

SSA-5062, Claimant Statement about Loan of Food or Shelter and

SSA-L5063 Statement about Food or Shelter Provided to Another

20 CFR 416.1130-1148

OMB No. 0960-0529

A. Justification

1. Forms SSA-5062 and SSA-L5063 are used in the administration of the Supplemental Security Income (SSI) program. Eligibility for SSI benefits is based on need. Need is measured by the amount of income an individual receives. Income includes in-kind support and maintenance in the form of food and shelter provided to the eligible individual by other persons.

Section 1612(a)(2)(A) of the Social Security Act (the Act) provides that the benefits of an eligible individual who receives in-kind support and maintenance in kind will be reduced by 33 and 1/3 percent. Section 1631(e)(1)(B) of the Act requires that information used to determine eligibility for SSI benefits must be verified by independent or collateral sources.

The regulations at 20 CFR 416.1130-1148 provide the rules for implementing Section 1612(a) (2) (A) of the Act.

2. The information obtained by forms SSA-5062 and SSA-L5063 is used by the Social Security Administration (SSA) to identify bona fide loans of food and shelter made to applicants for SSI benefits. This information permits SSA adjudicators to determine the income value of food and shelter received by SSI applicants. SSA needs this information to determine eligibility for SSI benefits and the amount of benefits payable.

Form SSA-5062 is completed by an SSI applicant or beneficiary who seeks to establish that food and shelter provided by another person is a loan which must be repaid. Form SSA-L5063 is completed by the person who provides the food and shelter to the SSI applicant or beneficiary. Together, these forms establish whether a bona fide loan exists between the applicant or beneficiary and the lender.

Failure to obtain such information would prevent SSA from making accurate determinations of eligibility and benefit amounts as required by statute.

. It should be noted that Forms SSA-5062 and SSA-L5063 usually are administered by SSA interviewers and the information collected is readily available to the respondents and requires no special record keeping. In addition, these forms are not used for all claims and posteligibility determinations, but only when they are needed to document the existence of a bona fide loan of food and shelter.

3. Improved information technology that could reduce the burden on respondents to these particular forms is not available. The respondents to these forms are typically SSI applicants or beneficiaries and other individuals who provide information about the living arrangements and household expenses in the SSI applicant’s or beneficiary’s place of residence. Such information about individual households is not available on any electronic database and can only be provided by the SSI applicant or beneficiary and the individual providing food and shelter because the information is based on the expenses in the particular household.

Forms SSA-5062 and SSA-L5063 are not used in all SSI claims and posteligibility determinations. They are used in a limited number of cases and only when this information is needed to determine whether a bona fide loan of food and shelter exists. These forms are used only after an SSA interviewer has already interviewed the applicant and collected enough information to determine that they are needed. Because these forms are used sparingly and only in situations identified by an SSA interviewer, we do not think that these forms would be useful for the general public on our web site. Putting these forms on the web site could result in members of the public completing them when they are not needed. In the relatively small number of cases for which we use this form, the applicant would have already spoken with an SSA interviewer who would complete this form for the applicant.

Forms SSA-5062 and SSA-L5063 are almost always completed with the assistance of an SSA interviewer. In our experience, self-help completion of these forms would be likely to result in confusion for the public due to the nature of the underlying policy. Furthermore, the information provided on these forms affects SSI eligibility and benefit amounts and, therefore, must be completed and signed only by the appropriate person; i.e., the applicant or beneficiary or their designated representative and the individual who provides the food and shelter. Accordingly, we take precaution to prevent misuse of the form. Unrestricted availability of these forms on the internet would permit their usage by other than the appropriate person and could result in program abuse. Based on case experience, we have found that some individuals do seek to use the loan policy as a way to get higher SSI payments than would otherwise be payable. For these reasons, SSA has determined that Forms SSA-5062 and SSA-L5063 are not appropriate forms for the internet.

4. The nature of the information being collected and the manner in which it is collected precludes duplication. No other collection instrument used by SSA collects data similar to that collected on these forms.

5. The information collected does not involve small business or other small entities. Therefore, the collection does not have any impact on small businesses or other small entities.

6. Collection of the information takes place based on the need of the applicant to apply for or reaffirm eligibility for SSI benefits. SSA collects this information only when the applicant or beneficiary alleges the existence of a loan of food and shelter. Not collecting this information would create a high risk of incorrect SSI eligibility and payment determinations. Less frequent collection would increase the risk of incorrect SSI eligibility and payment determinations.

7. There are no special circumstances that would cause this information collection to be conducted in a manner that is not consistent with 5 CFR 1320.5.

8. The first Federal Register notice was published on January 4, 2007 at 72 FR 357. The second notice was published on March 23, 2007 at 72 FR 13851. We have received no comments form the public as a result of these notices. There have been no outside consultations with members of the public

9. SSA provides no payments or gifts to the respondents.

10. The information provided on this form is protected and held confidential in accordance with 42 U.S.C. 1306, 20CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.

11. This information collection does not contain any questions of a sensitive nature.

12. When we need to verify a bona fide loan of food and shelter, both the SSA-5062 and the SSA-L5063 are completed. The SSA-5062 is used to record the statement of the applicant for SSI benefits or SSI beneficiary who alleges receiving a loan of food and shelter. The SSA-L5063 is used to record the statement of the person who provides the food and shelter to the applicant. This information is collected only on these paper forms. It is not collected on MSSICS or any other electronic system.

Form SSA-5062 will be used by approximately 65,540 respondents per year. Because the forms are used in tandem, Form SSA-L5063 will also be used by approximately 65,540 respondents per year for a total of 131,080. Based on experience using this form over several years, we estimate that the burden time is about 10 minutes per response form. This results in a combined total of 21,847 burden hours for both forms.

This request for approval covers both forms. The total burden is expressed as burden hours. No separate cost burden has been calculated.

13. There is no known cost burden to respondents. These forms collect only information that is readily available to the respondents. No additional record keeping by the respondent is needed or required. No special equipment is needed by the respondents to collect or store this information.

14. The annual cost to the Federal government for both forms is approximately $302,795 ($100,932 for the SSA-5062 and $201,863 for the SSA-5062). This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. There have been no program changes or adjustments in this form, and there is no change in the public reporting burden.

16. The results of this information collection will not be published.

17. OMB has granted SSA an exemption from the requirement that the expiration date for OMB approval be printed on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB clearance. SSA does not periodically revise and reprint its public-use forms, (e.g., on an annual basis). This exemption was granted so that otherwise useable editions of forms would not be taken out of circulation because the expiration date had been reached. In addition, government waste has been avoided because stocks of forms will not have to be destroyed and reprinted.

18. SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b) (3). Please note, however, that statistical survey methodology is not used for this information collection because it would not be feasible given the nature and the source of the information collected on these forms.

B. Collections of Information Employing Statistical Methods

Statistical methods are not used for this information collection.