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)
Destory Prior Editions

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

$

When will it be repaid?
5. 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)

See revised Privacy Act
and Paperwork Reduction
Collection and Use of Information From Your Application - Act statements below.
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)

Statement About Loan of Food or Shelter Provided to Another, Form SSA-L5063-F3
Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e)(1)(B) of the Social Security Act, as amended (42 U.S.C. 1383(e))
authorizes us to collect this information. We will use the information you provide to
identify bona fide loans of food and shelter made to applicants for Supplemental
Security Income (SSI) benefits. This information will permit us to determine an
income value, if any, of food and shelter received by the SSI applicant. The
information you provide on this form is voluntary. However, failure to provide all or
part of the requested information could prevent us from making an accurate and
timely decision on the SSI applicant’s claim or could result in the loss of his or her
benefits.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. 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, General
Services Administration, National Archives Records Administration, and the
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 and administered benefit
programs for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of
Records Notices entitled, Claims Folder System, 60-0089 and Supplemental Security
Income Record and Special Veterans Benefits System, 60-0103. These notices,
additional information regarding this form, and information regarding our programs
and systems, are available on-line at www.socialsecurity.gov or at your local Social
Security office.

SSA will insert the following revised PRA Statement 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. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.