Supporting Statement - 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 for 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 bases an SSI claimant or recipient’s eligibility on need, as measured by the amount of income an individual receives. Per our calculations, income includes other people providing in-kind support and maintenance in the form of food and shelter to SSI applicants or recipients. SSA uses Forms SSA-5062 and SSA‑L5063 to obtain statements about food or shelter provided to SSI claimants or recipients. SSA uses this information to determine whether food or shelters are bona fide loans or income for SSI purposes. This determination may affect claimants’ or recipients’ eligibility for SSI as well as the amounts of their SSI payments. 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

SSA claims representatives complete Form SSA-5062 and SSA-L5063 via telephone contact with the respondent, or in person at a local SSA field office. The claims representatives record the information in our electronic SSI Claim System. When the information is documented directly into the SSI Claim System, we do not use paper Form SSA-5062 and SSA-L5063-F3. In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Intranet version of Forms SSA-5062 and SSA-L-5063-F3. Based on our data, we estimate approximately 50% of respondents under this OMB number use the electronic version.

4. Why We Cannot Use Duplicate Information –

The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently If we did not use Forms SSA-5062 and SSA-L5063-F3, we would be unable to make accurate determinations of eligibility and SSI payment amounts as required by statute. Because we only collect the information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on June 8, 2018, at

83 FR 26732, and we received no public comments. The 30-day FRN published on August 6, 2018 at 83 FR 38442. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the development or revision/maintenance these forms.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

9. 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.

9. Justification for Sensitive Questions

This information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden of Response (minutes)	Total Estimated Annual Burden (hours)
SSA-5062 – Paper Version	30,632	1	10	5105
SSA-L5063 – Paper Version	30,632	1	10	5105
SSA-5062 – SSI claim system	30,632	1	10	105
SSA-L5063 – SSI claim system	30,632	1	10	5105
Total	122,528			20,420

The total burden for this ICR is 20,420 hours. We based these figures on current information management data. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

13. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $546,883. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time; and (3) systems development, updating, and maintenance costs.

15. Program Changes or Adjustments to the Information Collection Request When we last cleared this collection in 2015, the burden was 23,168 hours. However, we are currently reporting a burden of 20,420 hours. This change stems from a decrease in the number of responses from 139,000 to 122,528. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

16. 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.

16. 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 does not use statistical methods for this information collection.

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