Supporting Statement 0960-0529

Supporting Statement for Forms

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

SSA-L5063-F3, Statement about Food or Shelter Provided to Another

20 CFR 416.1130-1148

OMB No. 0960-0529

A. Justification

1. Introduction/Authoring Laws and Regulations – The Social Security Administration (SSA) uses Forms SSA-5062 and SSA-L5063-F3 as part of its administration of the Supplemental Security Income (SSI) program. SSA bases a claimant or recipient’s eligibility for SSI on need. We assess need by the amount of income an individual receives. Income includes other persons providing in-kind support and maintenance in the form of food and shelter to SSI claimants or recipients.

Section 1612(a)(2)(A) of the Social Security Act (Act) provides that SSA will reduce SSI payments by 33 and 1/3 percent of an SSI recipient who receives in-kind support and maintenance. Section 1631(e)(1)(B) of the Act requires SSA to verify, by independent or collateral sources, the information we use in determining eligibility for SSI.

The regulations at 20 CFR 416.1130-1148 provide the rules for implementing section 1612(a)(12)(A) of the Act.

2. Description of Collection – SSA uses the information obtained on Forms SSA-5062 and SSA-L5063-F3 to identify bona fide loans of food and shelter made to claimants and recipients for SSI. This information allows SSA adjudicators to determine the income value of food and shelter an SSI claimant or recipient receives. SSA needs this information to determine SSI eligibility and payment amounts.

An SSI applicant or recipient completes Form SSA-5062 when seeking to establish that food and shelter provided by another person is a repayable loan. The person providing the food and shelter to the SSI applicant or recipient completes Form SSA-L5063-F3. Together, these forms establish whether a bona fide loan exists between the SSI applicant or recipient and the lender. If a bona fide loan exists, SSA does not count the in-kind support and maintenance as income for purposes of determining SSI eligibility or payment amounts.

SSA interviewers usually administer Forms SSA-5062 and SSA-L5063-F3. The respondents are claimants and recipients for SSI payments, and individuals who provide loans of food or shelter to them.

3. Use of Information Technology to Collect the Information - Improved information technology that could reduce the burden on respondents to these particular forms is not available. The respondents are typically SSI applicants or recipients and other individuals who provide information about the living arrangements and household expenses in the SSI applicant or recipient’s place of residence. Such information about individual households is not available on any electronic database. The SSI applicant or recipient and the individual providing the food and shelter are the only sources for providing this information. The individuals providing the information are basing their statements on expenses in their particular household.

SSA uses these forms only after an SSA interviewer has already interviewed the applicant and collected enough information to determine if SSA needs them. Because we use these forms sparingly and only in situations identified by an SSA interviewer, we do not think these forms would be useful for the public on our website. If we were to put these forms on our website, members of the public may complete them unnecessarily.

In 2009, SSA revised its procedures for completing Form SSA-5062 and SSA-L5063-F3. The new procedure permits SSA claims representatives (CR) to collect the information on Form SSA-5062 and SSA-L5063-F3 by telephone contact with the respondent. CRs record the information on our electronic Modernized SSI Claims System (MSSICS). When we use this procedure, we do not use paper Forms SSA-5062 and SSA-L5063-F3. We estimate 50 percent of these collections use the telephone/MSSICS procedure.

4. Why We Cannot Use Duplicate Information - The nature of the information we are collecting and the manner in which we are collecting it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents - The collection has no impact on small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently – SSA does not use these forms for all SSI claims and post eligibility determinations, rather only when we need to document the existence of a bona fide loan of food and shelter, do we use these forms. Failure to obtain this information would prevent SSA from making accurate determinations of eligibility and SSI payment amounts as required by statute. SSA collects the information based on the need of the applicant to apply for, or reaffirm eligibility for, SSI. SSA collects this information only when the applicant or recipient alleges the existence of a loan of food and shelter. If we collected it less frequently, we would increase the risk of incorrect SSI eligibility and payment determinations. There are no technical or legal obstacles to burden reduction. In addition,

7. Special Circumstances - There are no special circumstances that would cause SSA to collect this information in a manner that is not consistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public – SSA published the 60-day advance Federal Register Notice on September 24, 2012 at 77 FR 58903, and we received no public comments. We published the second Notice on December 7, 2012, at 77 FR 73112. If we receive any comments in response to the 30-day Notice, we will forward them to OMB. We did not consult with the public in the maintenance of this form.

9. Payment or Gifts to Respondents - SSA provides no payments or gifts to the respondents.

10. Assurances of Confidentiality - SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. § 1306, 20 CFR 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. Justification for Sensitive Questions - This information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Approximately 69,800 respondents use Form SSA-5062 per year. Approximately 69,800 respondents will use Form SSA-L5063-F3 per year for 139,600 total respondents. We estimate the burden time is 10 minutes per response form. We collect approximately 50 percent of the information on paper forms and approximately 50 percent through the electronic MSSICS system. The following is a breakdown:

Modality of Collection	Number of Respondents	Frequency of Response	Average Burden of Response (minutes)	Total Estimated Annual Burden (hours)
SSA-5062 Paper form	34,900	1	10	5,817
SSA-L5063 Paper form	34,900	1	10	5,817
SSA-5062 MSSICS	34,900	1	10	5,817
SSA-L5063 MSSICS	34,900	1	10	5,817
Total	139,600			23,268

The total burden reflects burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents - There is no known cost burden to respondents.

14. Annual Cost to Federal Government - The annual cost to the Federal Government is approximately $435,061. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request – The increase in burden is due to an increase in respondents (i.e., increase of claimants/recipients in the SSI program).

16. Plans for Publication Information Collection Results - SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date - OMB granted SSA an exemption from the requirements to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

18. Exceptions to Certification Statement - 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).

B. Collections of Information Employing Statistical Methods

SSA did not use statistical methods for this information collection.