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 (12-2012)
Destroy 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?
Yes

2. What period of time did you provide
food and/or shelter to this individual?
From

No

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
you for this food and/or shelter?

5. Remarks:
How much will be repaid?

$

When will it be repaid?
6. Under the agreement to repay:

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 (12-2012)
Destroy Prior Editions

Collection and Use of Information From Your Application
Privacy Act Notice/Paperwork Reduction Act Notice
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
See revised
information will permit us to determine an income value, if any, of food and shelter received by
Privacy Act
the SSI applicant. The information you provide on this form is voluntary. However, failure to
statement
below.
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.
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 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.
Form SSA-L5063-F3 (12-2012)

Privacy Act Statement
Collection and Use of Personal Information
Sections 1612(a)(2)(A) and 1631(e)(1)(B) of the Social Security Act, as amended, authorize us
to collect this information. We will use this information to identify bona fide loans of food and
shelter made to Supplemental Security Income (SSI) applicants. We will use this information to
determine an income value, if any, of food and shelter the applicant received.
Furnishing us the information is voluntary. However, failing to provide all or part of the
requested information may prevent us from making an accurate and timely decision on the
applicant’s SSI claim or could result in the loss of benefits.
We rarely use the information you supply for any purpose other than for determining eligibility
for benefits. However, we may use the information for the administration of our programs
including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notices 60-0089, entitled Claims Folder System and 60-0103,
entitled Supplemental Security Income Record and Special Veterans Benefits System.
Additional information about these systems of records notices and our programs is available
from our Internet website at www.socialsecurity.gov or at your local Social Security office.
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. We use the information from these programs to establish or verify a person's eligibility
for Federally funded or administered benefit programs and for repayment of incorrect payments
or delinquent debts under these programs.