Information Collection

0960-0529 - SSA-L5063 (Paper Version)

IC 265548 under ICR 202402-0960-006 · OMB 0960-0838.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L506 0960-0529 - SSA-L5063 (Paper Version)	Form
Form SSA-L506 Statement about Food or Shelter Provided to Another 0960-0529 - SSA-L5063 (Paper Version)	Form
Form SSA-L5063 (to SSA- Statement about Food or Shelter Provided to Another 0960-0529 - SSA-L5063 (Paper Version)	Form
SSA-L506 Statement about Food or Shelter Provided to Another SSA-L5063 (gender inclusive language updates).pdf	Form
SSA-L506 Statement about Food or Shelter Provided to Another SSA-L5063 (gender inclusive language updates).pdf	Form
SSA-L5063 (to SSA- Statement about Food or Shelter Provided to Another Form SSA-L5063 change to Form SSA-L5065 effective 9-30-2024.pdf	Form
SSA-L5063 (to SSA- Statement about Food or Shelter Provided to Another Form SSA-L5063 change to Form SSA-L5065 effective 9-30-2024.pdf	Form
SSA-L5063 - Current Version.pdf Current SSA-L5063	IC Document
SSA-L5063 - Current Version.pdf Current SSA-L5063	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1201(a) 20 CFR 416.1102-416.1104 20 CFR 416.1121 20 CFR 416.1130 20 CFR 416.202

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L506	Statement about Food or Shelter Provided to Another	SSA-L5063 (gender inclusive language updates).pdf	www.ssa.gov	Yes	No	Fillable Printable
Form	SSA-L5063 (to SSA-L5065 Effective on 9/30/24)	Statement about Food or Shelter Provided to Another	Form SSA-L5063 change to Form SSA-L5065 effective 9-30-2024.pdf	www.ssa.gov	Yes	No	Fillable Printable

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	Program Change Due to New Statute
Annual Number of Responses for this IC	29,026	29,026
Annual IC Time Burden (Hours)	14,029	14,029
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-L5063	SSA-L5063 - Current Version.pdf	02/21/2024

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