Information Collection

0960-0529 SSA-L5063 (Paper version)

IC 262472 under ICR 202403-0960-007 · OMB 0960-0835.

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

0960-0529 SSA-L5063 (Paper version)

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 416.1100 20 CFR 416.1102 20 CFR 416.1104 20 CFR 416.1110 20 CFR 416.1120 20 CFR 416.1130-416.1148 20 CFR 416.1160-416.1161 20 CFR 416.1201

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 and Instruction	SSA-L5063			www.ssa.gov	Yes	No	Fillable Printable
Form and Instruction	SSA-L5063 (to SSA-L5065 Effective on 9/30/24)			www.ssa.gov	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,513

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 Agency Discretion
Annual Number of Responses for this IC	14,513	14,513
Annual IC Time Burden (Hours)	17,899	17,899
Annual IC Cost Burden (Dollars)	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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