Form SSA-L5061 Letter to Landlord Requesting Rental Information

Form Approved
OMB No. 0960-0454

SOCIAL SECURITY
Refer to:

We need information from you about the property described on the attached page. The facts you
provide will help us to decide whether
can receive payments from us, and if so, how much. The individual or the individual's representative
has given permission for us to obtain this information.
Please answer the questions on the other side of this page. We will use your answers to decide who is
responsible for payment of rent at the residence shown. We will also decide if the individual named
above receives a rental subsidy. A rental subsidy can occur when someone pays less for his home than
the landlord would charge other renters. If we decide that this person receives a rental subsidy, we
might make lower payments or decide no payments are due.
The Social Security Administration (SSA) may routinely give out the information collected on this
form without consent if a Federal law requires that we give out the information, or if a Federal or State
agency needs the information to decide whether the individual named above is eligible for a health or
income program such as SSI State supplementary payments, food stamps, Medicaid, energy assistance,
or unemployment insurance. Explanations about these and other reasons why information you provide
us may be used or given out are available in Social Security offices. If you want to learn more about
this, contact any Social Security office.
IF YOU HAVE QUESTIONS ABOUT THIS FORM, PLEASE CALL
ON TELEPHONE NUMBER
BETWEEN THE HOURS OF

ON MONDAY THROUGH FRIDAY
AND

.

We appreciate your cooperation in furnishing this information. For your convenience, we are
enclosing a reply envelope requiring no postage.
Sincerely,

Enclosure

Form SSA-L5061 (11-2014) EF (11-2014)
Destroy Prior Editions

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 the information you provide to help us determine the individual's
eligibility for benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making an accurate and timely decision on any claim for benefits.
We rarely use the information you supply for any purpose other than to complete our claims process.
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 complete list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notices 60-0103, entitled Supplemental Security Income Record,
Special Veterans Benefits and 60-0089, entitled Claims Folder. Additional information about these and
other system 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 share the information you provide to other health agencies through 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 - 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 5 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-L5061 (11-2014) EF (11-2014)

Are you the landlord for the residence at:
?

1.

Yes Go on to item 2.
No Complete item 6 below and return this form in the enclosed envelope.
Is

2.

the person you hold responsible

for payment of the rent for this residence?
Yes
No
How much rent do you charge?

$

3.

per
(month or week)

If someone other than

4.

rented this residence, how much would you charge?

$

per

(month or week)

If the amount you wrote in Item 3 is less than the amount you wrote in Item 4, why do you charge less
rent? (Explain)

5.

PHONE (Include area
code)

STREET
Address

6.

CITY
Signature (Sign Here)

STATE

ZIP CODE

DATE

Form SSA-L5061 (11-2014) EF (11-2014)