Form SSA-5062 Climant Statement About Loan of Food or Shelter

Form Approved
OMB NO. 0960-0529

Social Security Administration

CLAIMANT'S STATEMENT
ABOUT LOAN OF FOOD OR SHELTER
The information below refers to: (Claimant's Name)

Claimant's SSN

Name of Person Making Statement if other than Claimant

Relationship to Claimant

1. Name and address of person who provided you with food and/or shelter

2. Month(s) in which this person provided you with food and/or shelter
from

to

3. Have you and the above individual agreed that you will repay him/her for this food and/or shelter?
YES

If yes, go to question 4.

NO

If no, stop, sign, and date below.

4. When did you and the above individual establish the agreement that you will repay him/her for this food and/or shelter?

5. Under the agreement to repay:
How much will you repay?

$

When will you repay?
What funds will you use?
6. Have you started to repay this money?
YES

NO

I declare under penalty of perjury that I have examined all the information on this form and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge.
Signature

Date

Mailing Address

Telephone Number (Include area code)

Form SSA-5062 (12-2012) EF (12-2012)

PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Claimant’s Statement about Loan of Food or Shelter, Form SSA-5062
Sections 205 and 1631(e)(1)(B) of the Social Security Act, as amended, authorize us to collect
this information. We will use this information to identify bona fide food loans of food and
See revised
shelter made to Supplemental Security Income (SSI) applicants. We will use this information to
determine an income value, if any, ofPrivacy
food andAct
shelter the applicant received.

statement below.

Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from making an accurate and timely decision on the
applicant’s SSI claim or could result in the loss of benefits.
We rarely use the information for any purpose other than for making a decision regarding
entitlements to benefits. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose the information to another person or to another agency
in accordance with approved routine uses, which include, but are not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social
Security benefits and coverage;
2. To comply with Federal laws requiring the release of information from our
records (e.g. to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, and investigatory activities necessary to
assure the integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for federally-funded and administered benefit programs and for repayment
of payment’s or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act Systems of
Records Notices entitled, Claims Folders Systems, 60-0089 and Supplemental Security Income
Record and Special Veterans Benefits System, 60-0103. These notices, additional information
regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your
local Social Security office.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44
U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. You can find your local Social Security office through SSA's website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
Form SSA-5062 (12-2012) EF (12-2012)

Privacy Act Statement
Collection and Use of Personal Information
Sections 1612(a)(2)(A) and 1631(e)(1)(B) of the Social Security Act, as amended, authorize us
to collect this information. We will use this information to identify bona fide loans of food and
shelter made to Supplemental Security Income (SSI) applicants. We will use this information to
determine an income value, if any, of food and shelter the applicant received.
Furnishing us the information is voluntary. However, failing to provide all or part of the
requested information may prevent us from making an accurate and timely decision on your SSI
claim or could result in the loss of benefits.
We rarely use the information you supply for any purpose other than for determining eligibility
for benefits. However, we may use the information for the administration of our programs
including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notices 60-0089, entitled Claims Folder System and 60-0103,
entitled Supplemental Security Income Record and Special Veterans Benefits System.
Additional information about these systems of records notices and our programs is available
from our Internet website at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. We use the information from these programs to establish or verify a person's eligibility
for Federally funded or administered benefit programs and for repayment of incorrect payments
or delinquent debts under these programs.