Form SSA-L5063 Statement about Food or Shelter Provided to Another

Form SSA-L5063 (06-2017)
Discontinue Prior Editions
Social Security Administration

OMB No. 0960-0529

Refer to:

Social Security Office Address:

Dear:

Telephone Number:

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 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 questionnare. 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 (06-2017)
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0529

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?

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

Yes

No

From:

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, 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:

Address:

Telephone Number (include area code):

Page 2 of 2

Form SSA-L5063 (06-2017)

Privacy Act Statement
Collection and Use of Personal Information

See Revised
Privacy Act
Sections 1612(a)(2)(A) and 1631(e)(1)(B) of the Social Security Act, as amended,
authorize us to collect this
Statement
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.
See Revised PRA
Statement
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.