Statement About Food or Shelter Provided to Another

The attached MSSICS “LHID” screen establishes whether a bona fide loan of ISM (food or shelter) exists. The information is collected during the interviewing process. Form SSA-5062 (“Claimant’s Statement About Loan of Food or Shelter”) collects additional information necessary to support the claimant’s statement that he or she has a bona fide loan of ISM. The SSA-L5063-F3 (“Statement About Food or Shelter Provided to Another”) collects information from the lender to verify that the claimant has a bona fide loan of ISM.

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MSSICS                 HOUSEHOLD INCOME DATA                  LHID

                                [1-D]                      [2-O]

SSS-SS-SSSS  SSSSS SSSSSSSSSS   PERIOD BEGAN: SS/SS/SSSS   TRANSFER TO:  XXXX

            [3-M]

            ALL PUBLIC ASSISTANCE HOUSEHOLD (Y/N): X

            [4-C]

            PUBLIC ASSISTANCE WITH AFDC PAYMENT CAP HOUSEHOLD (Y/N): X

                  [5-C]

                  LOAN AGREEMENT REGARDING HOUSEHOLD EXPENSES  (Y/N): X

                    [6-C]

                    IF YES, BONA FIDE LOAN EXISTS (Y/N): X

                            [7-C]

                            IF YES, ASSUMED TO COVER PRO RATA SHARE (Y/N): X

                [8-O]

                DEVELOPMENT OF INSIDE ISM/UNSTATED INCOME NECESSARY (Y/N) : X

                                                                [9-O]

                                                                REMARKS(Y): X