Information Collection

Statement About Food or Shelter Provided to Another

IC 46358 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⚠️ Notice: This information collection may be referencing outdated material.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-L5063 Statement About Food or Shelter Provided to Another	Form
Form SSA-L5063 Statement about Food or Shelter Provided to Another Statement About Food or Shelter Provided to Another	Form
Revised PA Statement SSA-L5063.docx	Other-Revised Privacy Act Statement
Revised PA Statement SSA-L5063.docx	Other-Revised Privacy Act Statement
PRA 0529 (revised).docx	Other-Paperwork Reduction Act (revis
PRA 0529 (revised).docx	Other-Paperwork Reduction Act (revis
SSA-L5063 Statement about Food or Shelter Provided to Another SSA-5063 (revised).pdf	Form
SSA-L5063 Statement about Food or Shelter Provided to Another SSA-L5063 (2022 Mockup).pdf	Form

IC Title:

Statement About Food or Shelter Provided to Another

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.	Available Electronically?	Electronic Capability
Form	SSA-L5063	No	Paper Only
Other-Revised Privacy Act Statement		No	Paper Only
Other-Paperwork Reduction Act (revised)		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
	Approved	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)	40,636	35,531	5,105
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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