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

Social Security Administration

Form Approved 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, and 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 (4-2006) EF (4-2006)

Collection and Use of Information From Your Application -Privacy Act Notice/Paperwork Reduction Act Notice

We are authorized to collect the information on the enclosed questionnaire under section 1631 (e) (1) (B) of the Social Security Act, as amended (42 U.S.C. 1383 (e)). We will not give out any of the information you give us unless we are required to by law, or unless a Federal or State agency needs the information to decide whether the above individual is entitled to some type of benefit. The Federal register describes other situations when we might use this information. If you would like information about this, call us at the number listed at the top of this letter.

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. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. 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 (4-2006) EF (4-2006)