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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form SSA-L5063 Statement About Food or Shelter Provided to Another Form
Revised PA Statement SSA-L5063.docx Other-Revised Privacy Act Statement
PRA 0529 (revised).docx Other-Paperwork Reduction Act (revis
SSA-L5063 Statement about Food or Shelter Provided to Another SSA-5063 (revised).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-L5063	Statement about Food or Shelter Provided to Another	SSA-5063 (revised).pdf	No	Paper Only
Other-Revised Privacy Act Statement			Revised PA Statement SSA-L5063.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 %

	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

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.