Information Collection

Statement About Food or Shelter Provided to Another

IC 46358 under ICR 200612-0960-006 · OMB 0960-0529.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0529 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L5063 Statement About Food or Shelter Provided to Another	Form
SSA-L5063 Statement about Food or Shelter Provided to Another Revised SSA-L5063 Mock Up 090706.doc	Form
FACSIMILIE OF MSSICS HOUSEHOLD INCOME DATA SCREEN.doc MSSICS HOUSEHOLD INCOME DATA SCREEN	IC Document

IC Title:

Statement About Food or Shelter Provided to Another

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1130-1148

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L5063	Statement about Food or Shelter Provided to Another	Revised SSA-L5063 Mock Up 090706.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 65,540

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	65,540	65,540
Annual IC Time Burden (Hours)	10,923	10,923
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MSSICS HOUSEHOLD INCOME DATA SCREEN	FACSIMILIE OF MSSICS HOUSEHOLD INCOME DATA SCREEN.doc	03/01/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.