Supporting Statement - 0529 (Final)

Supporting Statement for Forms

SSA-5062, Claimant Statement about Loan of Food or Shelter and

SSA-L5063-F3, Statement about Food or Shelter Provided to Another

20 CFR 416.1130-1148

OMB No. 0960-0529

A. Justification

1. Introduction/Authoring Laws and Regulations

Section 1612(a)(2)(A) of the Social Security Act (Act) provides that SSA will reduce SSI payments by 33 and 1/3 percent for an SSI recipient who receives

in-kind support and maintenance. Section 1631(e)(1)(B) of the Act requires SSA to verify, by independent or collateral sources, the information we use in determining eligibility for SSI. The Regulations at 20 CFR 416.1130-1148 provide the rules for implementing Section 1612(a)(12)(A) of the Act.

2. Description of Collection

SSA bases an SSI claimant or recipient’s eligibility on need, as measured by the amount of income an individual receives. Per our calculations, income includes other people providing in‑kind support and maintenance in the form of food and shelter to SSI applicants or recipients. SSA uses Forms SSA-5062 and

SSA-L5063 to obtain statements about food or shelter provided to SSI claimants or recipients. SSA uses this information to determine whether food or shelters are bona fide loans or income for SSI purposes. This determination may affect claimants’ or recipients’ eligibility for SSI as well as the amounts of their SSI payments. The respondents are claimants and recipients for SSI payments, and individuals who provide loans of food or shelter to them.

3. Use of Information Technology to Collect the Information

SSA claims representatives complete Form SSA-5062 and SSA-L5063 via telephone contact with the respondent, or in person at a local SSA field office, and records the information in our electronic SSI Claim System.

This collection does not currently have a fully public-facing Internet version, as we prioritized other information collections for full electronic conversions. Given that IT Mod programming is an ongoing, dynamic project, we cannot provide specific timelines for when we will be able to make any particular ICR available via Internet web-based application.  We will ultimately convert most existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this may be unconnected to the PRA approval lifecycle. 

In the interim, we evaluated this collection for conversion to a submittable PDF.  Given the high volume of conversions we are coordinating and the more urgent nature of some of the other conversions, we ultimately decided not to prioritize this ICR for conversion to fully submittable PDF at this time.  When we are able to schedule this form for conversion to a submittable PDF, we will submit a Change Request to OMB to request prior approval.

4. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently If we did not use Forms SSA-5062 and SSA-L5063-F3, we would be unable to make accurate determinations of eligibility and SSI payment amounts as required by statute. Because we only collect the information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on July 27, 2021, at

86 FR 40221, and we received no public comments. The 30-day FRN published on September 29, 2021 at 86 FR 54007. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

9. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

9. Justification for Sensitive Questions

This information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

The chart below shows our burden information for this information collection:

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Annual (dollars)*	Average Wait Time in Field Office (minutes) **	Total Annual Opportunity Cost (dollars)**
SSA-5062 (Paper version)	29,026	1	10	4,838	$19.01*	24**	$312.676***
SSA-L5063 (Paper version)	29,026	1	10	4,838	$19.01*	24**	$312.676***
SSA-5062 (SSI claim system)	29,026	1	10	48,38	$19.01*	24**	$312.676***
SSA-L5063 (SSI claim system)	29,026	1	10	4,838	$19.01*	24**	$312.676***
Total	116,104			19,352			$1,250,704***

* We based this figure on average U.S. worker’s hourly wage, as reported by Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes_nat.htm), and on the average DI payments based on SSA's current FY 2021 data (https://www.ssa.gov/legislation/2021FactSheet.pdf).

** We based this figure on the average FY 2021 wait times for field offices, based on SSA’s current management information data.

*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

In addition, OMB’s Office of Information and Regulatory Affairs is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection. OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97 mile driving distance for one-way travel. We depict this on the chart below:

Total Number of Respondents Who Visit a Field Office	Frequency of Response	Average One-Way Travel Time to a Field Office (minutes)	Estimated Total Travel Time to a Field Office (hours)	Total Annual Opportunity Cost for Travel Time (dollars)****
116,104	1	30	58,052	$1,103,569****

****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the 5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.” SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data which shows that the average respondent drives to a field office, rather than using any other mode of transport. SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

NOTE: We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection.  Per our management information data, we believe that the average time in minutes listed in the chart above accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. Based on our current management information data, the current burden information we provided is accurate. The total burden for this ICR is 19,352 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $2,354,273. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

13. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $413,606. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$1,500
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$0*
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$408,686
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0*
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$3,420
Quantifiable IT Costs	Any additional IT costs	$0*
Total		$413,606

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have. It is difficult for us to break down the cost for processing a single form, as field office and State Disability Determination Services staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request When we last cleared this collection in 2018 the burden was 20,420 hours. However, we are currently reporting a burden of 19,352 hours. This change stems from a decrease in the number of responses from 122,528 to 116,104, due to fewer respondents applying for food and shelter assistance. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

16. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirements to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

16. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at

5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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