Statement About Food or Shelter Provided to Another

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