Form SSA-5062 Climant Statement About Loan of Food or Shelter

Form SSA-5062 (05-2019)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0529

CLAIMANT'S STATEMENT ABOUT LOAN OF FOOD OR SHELTER
The information below refers to: (Claimant's Name)

Claimant's SSN

Name of Person Making Statement if other than Claimant

Relationship to Claimant

1. Name and address of person who provided you with food and/or shelter

2. Month(s) in which this person provided you with food and/or shelter
From:

To:

3. Have you and the above individual agreed that you will repay him/her for this food and/or shelter?
Yes If yes, go to question 4.
No If no, stop, sign, and date below.
4. When did you and the above individual establish the agreement that you will repay him/her for this food and/or shelter?

5. Under the agreement to repay:
How much will you repay? $
When will you repay?
What funds will you use?
6. Have you started to repay this money?
Yes

No

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-5062 (05-2019)

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Privacy Act Statement
Collection and Use of Personal Information

See Revised
Privacy Act
Statement

Sections 1612(a)(2)(A) and 1631(e)(1)(B) of the Social Security Act, as amended, allow us to collect this information. Furnishing
us this information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate
and timely decision on a claim for Supplemental Security Income (SSI) or could result in the loss of benefits.
We will use the information to identify bona fide loans of food and shelter and determine an income value, if any, of food and
shelter received. We may also share your information for the following purposes, called routine uses:
• To third party contacts, where necessary, to establish or verify information provided by representative payees or payee
applicants; and
• To State agencies, to enable them to assist in the effective and efficient administration of the SSI program.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, entitled Claims
Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784, and 60-0103, entitled SSI Record
and Special Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830. Additional information, and a full
listing of all our SORNs, is available on our website at www.ssa.gov/privacy.

See Revised PRA
Statement

Paperwork Reduction Act - 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.