SSA-L5063 Statement about Food or Shelter Provided to Another

Form Approved
OMB NO. 0960-0529

Social Security Administration

STATEMENT ABOUT FOOD OR SHELTER
PROVIDED TO ANOTHER
The information below refers to: (Claimant's Name)

Claimant's SSN

1. Did you provide food and/or shelter to the
above individual?

2. What period of time did you provide food
and/or shelter to this individual?

YES

NO

FROM

TO

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

If yes, go to question 4

NO

If no, stop, and sign and date below.

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

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

$

When will it be repaid?
6. Remarks:

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-L5063-F3 (6-2007)