Claimant Statement About Loan of Food or Shelter

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

SSI Claims System Screens

Claimant Statement About Loan of Food or Shelter

OMB: 0960-0529

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Screen Shots for SSI claim system Household Expenses and Contributions Page
The attached SSI claim system “Household Expenses and Contributions” page establishes whether a bona fide loan
of ISM (food or shelter) exists. The information is collected during the interviewing process. Form SSA-5062
(“Claimant’s Statement About Loan of Food or Shelter”) collects additional information necessary to support the
claimant’s statement that he or she has a bona fide loan of ISM. The SSA-L5063-F3 (“Statement About Food or
Shelter Provided to Another”) collects information from the lender to verify that the claimant has a bona fide loan of
ISM.
FACSIMILE 1: HOUSEHOLD EXPENSES AND CONTRIBUTIONS
[1-D]
PERIOD EFFECTIVE DATES SS/SS/SSSS – SS/SS/SSSS
HOUSEHOLD EXPENSES AND CONTRIBUTIONS
*INDICATES REQUIRED INFORMATION
[2-M]
*ALL PUBLIC ASSISTANCE HOUSEHOLD
( ) YES (X) NO ( ) UNKNOWN
[3-C]
*PUBLIC ASSISTANCE WITH TEMPORARY ASSISTANCE FOR NEEDY FAMILIES PAYMENT CAP HOUSEHOLD
( ) YES (X) NO ( ) UNKNOWN
[12-C]
*LOAN AGREEMENT REGARDING HOUSEHOLD EXPENSES
( ) YES ( ) NO ( ) UNKNOWN
[14-C]
*BONA FIDE LOAN EXISTS
( ) YES ( ) NO ( ) UNKNOWN

[13-O]
MORE INFO

[15-C]
*ASSUMED TO COVER PRO RATA SHARE
( ) YES ( ) NO ( ) DECIDE LATER
[16-O]
[ ] DEVELOP INSIDE IN-KIND SUPPORT AND MAINTENANCE OR UNSTATED INCOME
[17-C]
*DO OTHERS CONTRIBUTE TO HOUSEHOLD EXPENSES
( ) YES ( ) NO ( ) UNKNOWN
[18-C]
*EATS ALL MEALS OUT
( ) YES ( ) NO ( ) UNKNOWN
[19-C]
*BUYS FOOD SEPARATE FROM HOUSEHOLD
( ) YES ( ) NO ( ) UNKNOWN
CONTRIBUTION AVERAGE PERIOD
[20-C]
[21-C]
*DATE FROM [] UNKNOWN
*DATE TO
PP/PPPP
PP/PPPP
(MM/YYYY)
(MM/YYYY)

[] UNKNOWN

[22-C]
*AMOUNT OTHERS CONTRIBUTE $9999.99 [ ] UNKNOWN
[23-C]
*MONTHLY LOAN AMOUNT $9999.99 [ ] UNKNOWN

[13-O]
MORE INFO

[24-C]
*CLAIMANT’S CONTRIBUTION $9999.99 [ ] UNKNOWN
EXPENSE AVERAGE PERIOD
[25-C]
[26-C]
*DATE FROM
[ ] UNKNOWN *DATE TO
[ ] UNKNOWN
PP/PPPP
PP/PPPP
(MM/YYYY)
(MM/YYYY)
*MONTHLY EXPENSES
FOR THE PERIOD ABOVE, COLLECT THE FOLLOWING EXPENSES
[27-C]
[28-P]
[29-C]
[30-C]
[31-C]
*FOOD($) *MORTGAGE *PROPERTY
*PROPERTY *HEATING
OR RENT($) INSURANCE($)
TAXES($)
FUEL($)
9999.99
PPPP.PP
9999.99
9999.99
9999.99
[35-C]
*WATER($)
9999.99

[32-C]
[33-C]
[34-C]
*ELECTRICITY($) *GAS($)
*GARBAGE
REMOVAL($)
9999.99
9999.99
9999.99

[36-C]
[37-O]
*SEWER($) UNKNOWN
9999.99
[]

[38-D]
TOTAL MONTHLY EXPENSES $SSSSS.SS
[39-D]
PRO RATA SHARE FOR (CLAIMANT FIRST NAME + LAST NAME) – (SSN) – (RELATIONSHIP) $SSSS.SS
DEEMOR CONTRIBUTION
[40-D]
DEEMOR

[41-C]
[42-D]
*DEEMOR
DEEMOR
CONTRIBUTION EXCESS
AMOUNT($)
CONTRIBUTION($)
(FIRST NAME + LAST NAME) – (SSN) – (RELATIONSHIP) 9999.99
SSSS.SS

[44-D]
TOTAL CONTRIBUTION FOR CLAIMANT $SSSS.SS

[43-D]
CLAIMANT’S
SHARE OF
EXCESS($)
SSSS.SS

[37-O]
UNKNOWN

[]

[45-D]
CLAIMANT’S EXCESS CONTRIBUTION $SSSS.SS
[46-D]
INSIDE ISM TO (CLAIMANT FIRST NAME + LAST NAME) – (SSN) – (RELATIONSHIP) $SSSS.SS
[47-D]
CASH FROM WITHIN HOUSEHOLD TO (CLAIMANT FIRST NAME + LAST NAME) – (SSN) – (RELATIONSHIP) $SSSS.SS
[48-C]
*CONTRIBUTION VERIFICATION RECEIVED
( ) YES ( ) NO
[7-O]
[˅/˄] SHOW/HIDE PERSON REMARKS
[8-O]
PERSON REMARKS (PRINTED)
XX[MAXIMUM OF 1000 CHARACTERS]XX
[9-O]
[˅/˄] SHOW/HIDE FILE DOCUMENTATION NOTES
[10-O]
FILE DOCUMENTATION NOTES
XX[MAXIMUM OF 1000 CHARACTERS]XX
[11-O]
[CLEAR PAGE/UNDO CHANGES]

SCREEN SHOT 1: HOUSEHOLD EXPENSES AND CONTRIBUTIONS


File Typeapplication/pdf
AuthorLevingston, Tamara
File Modified2018-08-08
File Created2018-08-08

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