Claimant Statement About Loan of Food or Shelter; Statement about Food or Shelter Provided to Another

Forms and Documents

Document Name	Status
Form SSA-L5063 Statement About Food or Shelter Provided to Another Form	Modified
Form SSA-L5063 Statement About Food or Shelter Provided to Another Form	Modified
Form SSA-5062 Claimant Statement About Loan of Food or Shelter Form	Modified
Form SSA-5062 Claimant Statement About Loan of Food or Shelter Form	Modified
Justification for Non-Substantive Change 0960-0529.docx Justification for No Material/Nonsubstantive Change	2024-10-17
Justification for Non-Substantive Change 0960-0529.docx Justification for No Material/Nonsubstantive Change	2024-10-17
Supporting Statement - 0529 (Final).docx Supporting Statement A	2024-07-24
Supporting Statement - 0529 (Final).docx Supporting Statement A	2024-07-24

IC Document Collections

IC ID	Document Title	Status
46358	Statement About Food or Shelter Provided to Another Form	Modified
46358	Statement About Food or Shelter Provided to Another Form	Modified
43703	Claimant Statement About Loan of Food or Shelter Form	Modified
43703	Claimant Statement About Loan of Food or Shelter Form	Modified
192187	Statement About Food or Shelter Provided to Another Other-Electronic Screens	Unchanged
192186	Claimant Statement About Loan of Food or Shelter Other-Electronic Screens	Unchanged

ICR Details

OMB Control No: 0960-0529	ICR Reference No: 202410-0960-011
Status: Active	Previous ICR Reference No: 202106-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: Claimant Statement About Loan of Food or Shelter; Statement about Food or Shelter Provided to Another
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/22/2024
	Date Received in OIRA: 10/17/2024
Terms of Clearance: In accordance with 5 CFR 1320, this information collection is approved.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2027	08/31/2027	08/31/2027
Responses	116,104	0	116,104
Time Burden (Hours)	152,870	0	152,870
Cost Burden (Dollars)	0	0	0

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Abstract: SSA bases an SSI claimant or recipient’s eligibility on need, as measured by the amount of income an individual receives. Per our calculations, income includes other people providing in-kind support and maintenance in the form of food and shelter to SSI applicants or recipients. SSA uses Forms SSA-5062 and SSA-L5063 to obtain statements about food or shelter provided to SSI claimants or recipients. SSA uses this information to determine whether food or shelters are bona fide loans or income for SSI purposes. This determination may affect claimants’ or recipients’ eligibility for SSI as well as the amounts of their SSI payments. The respondents are claimants and recipients for SSI payments, and individuals who provide loans of food or shelter to them. We are submitting this Non-Substantive Change Request to remove the signature requirement and replacing the Penalty of Perjury Statement with a Penalty of Perjury Warning.

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Authorizing Statute(s): US Code: 42 USC 1393 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 40221	07/27/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 54009	09/29/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Claimant Statement About Loan of Food or Shelter
Claimant Statement About Loan of Food or Shelter	SSA-5062	Climant Statement About Loan of Food or Shelter
Statement About Food or Shelter Provided to Another
Statement About Food or Shelter Provided to Another	SSA-L5063	Statement about Food or Shelter Provided to Another

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	116,104	116,104	0	0	0	0
Annual Time Burden (Hours)	152,870	152,870	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $413,606

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/17/2024

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