SSA-L5061 Letter To Landlord Requesting Rental Information

Form SSA-L5061 (XX-20XX) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 3
OMB No. 0960-0454

Letter To Landlord Requesting Rental Information
Refer to:

The Social Security Administration (SSA) needs 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.
We 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

Page 2 of 3
1.

Form SSA-L5061 (XX-20XX) UF

Are you the landlord for the residence at:
?
Yes Go on to item 2.
No Complete item 6 below and return this form in the enclosed envelope.

2.

Is
for this residence?

the person you hold responsible for payment of the rent

Yes Go on to item 2.
No Complete item 6 below and return this form in the enclosed envelope.
3.

How much rent do you charge?

$

per
(month or week)

4.

If someone other than
would you charge? $

rented this residence, how much
per
(month or week)

5.

Address

Phone
(include area code)

Street

City
Signature (Sign Here)

State

ZIP Code
Date

Page 3 of 3

Form SSA-L5061 (XX-20XX) UF
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.

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 5 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.