Form SSA-L5061 Letter to Landlord Requesting Rental Information

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See Revised Privacy Act Statement Attached

See Revised PRA Attached

The following revised PRA Statement will be inserted into the form at its next
scheduled reprinting:
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 (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.

The following revised Privacy Act Statement will be inserted into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 702 of the Social Security Act, as amended, authorizes us to collect this information. The
information you provide will be used to establish rent paid by an applicant for benefits, and whether that
applicant receives a rental subsidy.
The information you furnish on this form is voluntary. However, failure to provide the requested
information may prevent us from issuing benefits to the applicant.
We rarely use the information you supply for any purpose other than for establishing rent paid and amount,
if any, of a rental subsidy. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in accordance with
approved routine uses, which include but are not limited to the following:
1.

To enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;

2.

To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and Department of Veterans’ Affairs);

3.

To make determinations for eligibility in similar health and income maintenance programs at
the Federal, state and local level; and

4.

To facilitate statistical research, audit or investigative activities necessary to assure the
integrity of Social Security programs.

We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, state or local government agencies. Information
from these matching programs can be used to establish or verify a person’s eligibility for Federally funded
or administered benefit programs and for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and systems, is
available on-line at www.ssa.gov or at your local Social Security office.