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

Form SSA-5062 (07-2017)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0529

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-55062 (07-2017)

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Privacy Act StatementSee Revised
Privacy Act
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
Statement
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.

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.

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
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, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent us from making an accurate and timely
decision on a claim for Supplemental Security Income (SSI) or could result in the loss of
benefits.
We will use the information to identify bona fide loans of food and shelter and determine an
income value, if any, of food and shelter received. We may also share your information for the
following purposes, called routine uses:
•

To third party contacts, where necessary, to establish or verify information provided by
representative payees or payee applicants; and

•

To State agencies, to enable them to assist in the effective and efficient administration of
the SSI program.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, and 60-0103, entitled SSI Record and Special Veterans Benefits,
as published in the FR on January 11, 2006, at 71 FR 1830. Additional information, and a full
listing of all our SORNs, is available on our website at www.ssa.gov/privacy.