Statement About Food or Shelter Provided to Another

The attached MSSICS “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.