Information Collection

Statement About Food or Shelter Provided to Another

IC 46358 under ICR 202410-0960-011 · OMB 0960-0529.

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
SSA-L5063 Statement about Food or Shelter Provided to Another SSA-L5063 (revised).pdf	Form
SSA-L5063 Statement about Food or Shelter Provided to Another SSA-L5063 (revised).pdf	Form
SSA-L5063 (current).pdf SSA-L5063 (current)	IC Document
SSA-L5063 (current).pdf SSA-L5063 (current)	IC Document

IC Title:

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L5063				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	Previously Approved
Annual Number of Responses for this IC	29,026	29,026
Annual IC Time Burden (Hours)	40,636	40,636
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-L5063 (current)		10/17/2024

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

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