Information Collection

Claimant Statement About Loan of Food or Shelter

IC 43703 under ICR 200912-0960-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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-5062 Claimant Statement About Loan of Food or Shelter	Form
SSA-5062 Climant Statement About Loan of Food or Shelter SSA 5062.pdf	Form

IC Title:

Claimant Statement About Loan of Food or Shelter

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-5062	Climant Statement About Loan of Food or Shelter	SSA 5062.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 32,770

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	32,770	-65,540	32,770	65,540
Annual IC Time Burden (Hours)	5,462	-10,923	5,462	10,923
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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