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⚠️ Notice: This information collection may be referencing outdated material.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 SSA L5063.pdf Form
SSA L5063 current version.pdf SSA-L5063 Current Version 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: Modified

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	SSA L5063.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 34,900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	34,900	2,130	32,770
Annual IC Time Burden (Hours)	5,817	355	5,462
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-L5063 Current Version	SSA L5063 current version.pdf	11/26/2012

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