Information Collection

Claimant Statement About Loan of Food or Shelter

IC 43703 under ICR 202106-0960-003 · OMB 0960-0529.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0529 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5062 Claimant Statement About Loan of Food or Shelter	Form
Form SSA-5062 Climant Statement About Loan of Food or Shelter Claimant Statement About Loan of Food or Shelter	Form
Revised PA Statement SSA-5062 .docx	Other-Privacy Act Statement (revised
PRA 0529 (revised).docx	Other-Paperwork Reduction Act (revis
SSA-5062 Climant Statement About Loan of Food or Shelter SSA-5062 (revised).pdf	Form
SSA-5062 (curent).pdf SSA-5062 Current Version	IC Document

IC Title:

Claimant Statement About Loan of Food or Shelter

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1130-1148

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-5062	Climant Statement About Loan of Food or Shelter	SSA-5062 (revised).pdf	No	Paper Only
Other-Privacy Act Statement (revised)			Revised PA Statement SSA-5062 .docx	No	Paper Only
Other-Paperwork Reduction Act (revised)			PRA 0529 (revised).docx	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 29,026

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	29,026	-1,606	30,632
Annual IC Time Burden (Hours)	4,838	-267	5,105
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-5062 Current Version	SSA-5062 (curent).pdf	09/13/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.