Form SSA-L5063 Statement about Food or Shelter Provided to Another

Form Approved OMB NO. 0960-0529

Social Security Administration

Refer to:

Social Security Office Address:

Telephone Number:

Dear

We need information about the food and shelter you provided to

He/she authorized us to contact you about any food and shelter you may have provided to him/her.

This information will help us decide if this person can receive Supplemental Security Income and the amount of the payments. Your response is voluntary. However, if you do not respond, we may not be able to determine if this person can receive payments. Please see page two for more information on our collection and use of this information.

Please fill out the attached questionnaire. Return it to us in the enclosed postage-paid envelope. If you have any questions, please call us at the telephone number above. Thank you for your cooperation.

Sincerely yours.

Enclosure: Envelope

Form SSA-L5063-F3 (4-2006) Destroy Prior Editions

Social Security Administration

Form Approved OMB NO. 0960-0529

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 your 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 (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-L5063-F4 (4-2006)