Statement About Food or Shelter Provided to Another

Claimant Statement About Loan of Food or Shelter; Statement about Food or Shelter Provided to Another

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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 SSA-5063 Revised Version.pdf Form
SSA-5063 Current Version.pdf SSA-L5063 Current Version IC Document

Information Collection (IC) Details

IC Title:	Statement About Food or Shelter Provided to Another	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:

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	SSA-5063 Revised Version.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: 34,752	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	34,752	-148	34,900
Annual IC Time Burden (Hours)	5,792	-25	5,817
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-L5063 Current Version	SSA-5063 Current Version.pdf	07/14/2015

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