SSA-L5063 (to SSA- Statement about Food or Shelter Provided to Another

Form SSA-L5063 (XX-20XX)
Discontinue Prior Editions
Social Security Administration

OMB No. 0960-0529

Refer to:

Social Security Office Address:

Dear:

Telephone Number:

We need information about the food and shelter you provided to:

He/she authorized us to contact you about any food and shelter you may have provided to him/her.
This information will help us decide if this person can receive Supplemental Security income and the amount
of payments. Your response is voluntary. However, if you do not respond, we may not be able to determine
if this person can receive payments. Please see page two for more information on our collection and use of
this information.
Please fill out the attached questionnare. Return it to us in the enclosed postage-paid envelope. If you have
any questions, please call us at the telephone number above. Thank you for your cooperation.
Sincerely yours,

Enclosure:
Envelope

Form SSA-L5063 (XX-20XX)
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0529

STATEMENT ABOUT FOOD OR SHELTER PROVIDED TO ANOTHER
The information below refers to: (Claimant's Name)

Claimant's SSN:

1. Did you provide food and/or shelter to the above
individual?

2. What period of time did you provide food and/or
shelter to this individual?

Yes

From:

No

To:

3. Have you and the above individual agreed that he/she will repay you for this food and/or shelter?
Yes

If Yes, go to question 4.

No

If No, stop, sign and date below.

4. When did you and the above individual establish the agreement that he/she will repay you for this food
and/or shelter? NOTE: If you know a specific date, please provide it. Otherwise, please estimate to the
best of your ability.

5. Under the agreement to repay
(NOTE: If you do know precise amounts or repayment dates, please estimate to the best of your ability):
How much will be repaid?
When will it be repaid?
6. Has the individual started to repay the money?
Yes

No

I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge
Signature:

Date:

Address:

Telephone Number (include area code):

Page 2 of 2

Form SSA-L5063 (XX-20XX)

Privacy Act Statement
Collection and Use of Personal Information

Sections 1612(a)(2)(A) and 1631(e)(1)(B) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate and timely decision on a claim for Supplemental
Security Income (SSI) or could result in the loss of benefits.
We will use the information to identify bona fide loans of food and shelter and determine an income value, if
any, of food and shelter received. We may also share your information for the following purposes, called
routine uses:
·

To third party contacts, where necessary, to establish or verify information provided by representative
payees or payee applicants; and

·

To State agencies, to enable them to assist in the effective and efficient administration of the SSI
program.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person's eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089,
entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784,
and 60-0103, entitled SSI Record and Special Veterans Benefits, as published in the FR on January 11,
2006, at 71 FR 1830. Additional information, and a full listing of all our SORNs, is available on our website
at www.ssa.gov/privacy.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. §
3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number. We estimate that it
will take about 10 minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local
Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.