Statement About Food or Shelter Provided to Another

Claimant Statement About Loan of Food or Shelter; Statement about Food or Shelter Provided to Another

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0529 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-L5063 Statement About Food or Shelter Provided to Another Form
SSA-L5063 Statement about Food or Shelter Provided to Another Revised SSA-L5063 Mock Up 090706.doc Form
FACSIMILIE OF MSSICS HOUSEHOLD INCOME DATA SCREEN.doc MSSICS HOUSEHOLD INCOME DATA SCREEN IC Document

Information Collection (IC) Details

IC Title:	Statement About Food or Shelter Provided to Another	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1130-1148

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L5063	Statement about Food or Shelter Provided to Another	Revised SSA-L5063 Mock Up 090706.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 65,540	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	65,540	65,540
Annual IC Time Burden (Hours)	10,923	10,923
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
MSSICS HOUSEHOLD INCOME DATA SCREEN	FACSIMILIE OF MSSICS HOUSEHOLD INCOME DATA SCREEN.doc	03/01/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.