Current SSA-L5061

Form Approved
OMB No. 0960-0454

SOCIAL SECURITY
Refer to:

We need information from you about the property described on the attached page. The facts you
provide will help us to decide whether
can receive payments from us, and if so, how much. The individual or the individual's representative
has given permission for us to obtain this information.
Please answer the questions on the other side of this page. We will use your answers to decide who is
responsible for payment of rent at the residence shown. We will also decide if the individual named
above receives a rental subsidy. A rental subsidy can occur when someone pays less for his home than
the landlord would charge other renters. If we decide that this person receives a rental subsidy, we
might make lower payments or decide no payments are due.
The Social Security Administration (SSA) may routinely give out the information collected on this
form without consent if a Federal law requires that we give out the information, or if a Federal or State
agency needs the information to decide whether the individual named above is eligible for a health or
income program such as SSI State supplementary payments, food stamps, Medicaid, energy assistance,
or unemployment insurance. Explanations about these and other reasons why information you provide
us may be used or given out are available in Social Security offices. If you want to learn more about
this, contact any Social Security office.
IF YOU HAVE QUESTIONS ABOUT THIS FORM, PLEASE CALL
ON TELEPHONE NUMBER
BETWEEN THE HOURS OF

ON MONDAY THROUGH FRIDAY
AND

.

We appreciate your cooperation in furnishing this information. For your convenience, we are
enclosing a reply envelope requiring no postage.
Sincerely,

Enclosure

Form SSA-L5061 (07-2013) EF (07-2013)
Destroy Prior Editions

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1611, and 1631 of the Social Security Act, as amended, [42 U.S.C. 405(a)], [42 U.S.C.
1382], and [42 U.S.C. 1383] authorize us to collect this information. We will use the information you
provide to help us determine the individual’s eligibility for benefits. The information you provide on
this form is voluntary. However, failure to provide all or part of the requested information may prevent
us from making an accurate and timely decision on any claim for benefits.
See Revised Privacy Act Statement Attached
We rarely use the information you provide on this form for any purpose other than for the reasons
explained above. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in accordance with
approved routine uses, including but not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits
and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office, General Services Administration, National Archives Records
Administration, and the Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity
and improvement of our programs (e.g., to the U.S. Census Bureau and to private entities under
contract with us).
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies. We use
the information from these programs to establish or verify a person’s eligibility for Federally-funded or
administered benefit programs and for repayment of incorrect payments or delinquent debts under
these programs.
A complete list of routine uses of the information you gave us is available in our Privacy Act Systems
of Records Notices entitled, Supplemental Security Income Record and Special Veterans Benefits,
60-0103; Claims Folder System, 60-0089; and Electronic Disability (eDIB) Claims File, 60-0340. The
notices, additional information regarding this form, and information regarding our systems and
programs, are available on-line at www.socialsecurity.gov or at any Social Security office.

PAPERWORK REDUCTION ACT - 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 (OMB) control
number. The OMB control number for this collection is 0960-0454. We estimate that it will take about
10 minutes to read the instructions, gather the facts, and answer the questions. Send only comments
relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-L5061 (07-2013) EF (07-2013)

Are you the landlord for the residence at:
?

1.
Yes Go on to item 2.
No Complete item 6 below and return this form in the enclosed envelope.
Is

2.

the person you hold responsible

for payment of the rent for this residence?
Yes
No
How much rent do you charge?

$

3.

per
(month or week)

If someone other than

4.

rented this residence, how much would you charge?

$

per
(month or week)

If the amount you wrote in Item 3 is less than the amount you wrote in Item 4, why do you charge less
rent? (Explain)

5.

PHONE (Include area
code)

STREET
Address

6.

CITY
Signature (Sign Here)

STATE

ZIP CODE

DATE

Form SSA-L5061 (07-2013) EF (07-2013)

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
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, authorize us
to collect this information. We will use the information you provide to help us determine the
individual’s eligibility for benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making an accurate and timely decision on any claim for
benefits.
We rarely use the information you supply for any purpose other than to complete our claims
process. However, we may use the information for the administration of our programs including
sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices 60-0103, entitled Supplemental Security
Income Record, Special Veterans Benefits and 60-0089, entitled Claims Folder. Additional
information about these and other system of records notices and our programs is available from
our Internet website at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.