Supporting Statement - 0529 (Final)

Supporting Statement for Forms

SSA-5062, Claimant Statement about Loan of Food or Shelter and

SSA-L5063-F3, Statement about Food or Shelter Provided to Another

20 CFR 416.1130-1148

OMB No. 0960-0529

A. Justification

1. Introduction/Authoring Laws and Regulations

Section 1612(a)(2)(A) of the Social Security Act (Act) provides that SSA will reduce SSI payments by 33 and 1/3 percent for an SSI recipient who receives

in-kind support and maintenance. Section 1631(e)(1)(B) of the Act requires SSA to verify, by independent or collateral sources, the information we use in determining eligibility for SSI. The Regulations at 20 CFR 416.1130-1148 provide the rules for implementing Section 1612(a)(12)(A) of the Act.

2. Description of Collection

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 (ISM) in the form of food and shelter to SSI applicants or recipients. When SSA determines that a respondent is receiving in-kind support and maintenance of food or shelter , it will typically reduce the total SSI benefit available to the respondent,. For example, on January 1, 2021, Mary Johnson moved in with her son and her grandchildren and received both food and shelter from within the household. She did not help pay for the household expenses. Because she received food and shelter from her son, throughout the month, we would reduce her monthly SSI benefits by one-third. If she does not have any other countable income, her SSI payment would be reduced from $794 to $529.34.

However, food and shelter that are provided to a claimant as a loan do not trigger the one-third reduction, as they do not constitute income . Section 20 CFR 416.1103 (f) defines the income policy, and how a loan is treated. SSA does not define a loan as income. A Bona fide loan only means that the loan is real. SSA developed the requirements for establishing a bona fide loan for SSI purpose., SSA has five requirements that must be met to affirm that the contribution was in fact a bona fide loan. These are that:

• the agreement is enforceable under State law (it may be an oral or written agreement);

• the agreement in effect at time ISM provided;

• there is an acknowledgement of an obligation to repay;

• there is a plan or schedule for repayment;

• the repayment plan must be feasible.

SSA uses Forms SSA-5062 and SSA-L5063 to obtain statements about food or shelter provided to SSI claimants or recipients to determine whether food or shelters are bona fide loans or income for SSI purposes. It will initiate the use of these forms when it has identified that a claimant is receiving ISM but that the claimant has alleged that the ISM is a loan. The SSA-5062 is provided to the claimant who has received the ISM. In most circumstances, SSA will verbally ask these questions during an in-person interview at a field office or it will conduct the interview over the phone. If the field office cannot conduct an interview, it will mail the form to the respondent. The mailed form will include a cover letter explaining the purpose of the form, as well as a self-addressed envelope to allow for the return of the form.

The questions asked on Forms SSA-5062 and SSA-L5063 are used to help SSA determine if a bona fide loan is in place. The responses obtained on each form are compared to one another, which is why questions mirror reach other. The claimant or recipient and the lender must agree to the following: that a loan exist, start and ending time of the loan, on the amount of the loan, acknowledge that the loan has to be paid back in full, time period for repayment, and the repayment is feasible. The questions reflect the criteria needed to qualify a loan as bona fide.

We ask questions regarding basic biographic information about the claimant to establish the lender information and to confirm who the loan agreement is with; questions to determine the months in which food and or shelter was provided, because the loan agreement must have start dates; questions to determine if an agreement has been made, because it establishes that the claimant, or recipient and the lender agree that a loan exists; questions about repayment amounts, payment dates, and funds that will be used, because it provides SSA with the amount of the loan, payment date(s), and how the claimant plans on paying the lender back; questions to determine if repayments have started, because it informs SSA if the claimant or recipient has started to pay the loan. Asking these questions allows SSA to determine if the requirements are met to affirm that the contributions are in fact a bona fide loan, and are not income. SSA may also ask the respondent to provide documentation evincing the loan agreement.

Once SSA has received sufficient information regarding the loan from the claimant, it will attempt to corroborate this information with the lender. It will use SSA-5063 for this purpose. Similar to the SSA-5062, the field office will attempt to collect this information via an in-person interview or phone call with the respondent. If it cannot successfully speak to the respondent, it will send the form in the mail with a cover letter explaining why SSA needs the information.

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.

3. Use of Information Technology to Collect the Information

SSA claims representatives complete Form SSA-5062 and SSA-L5063 via telephone contact with the respondent, or in person at a local SSA field office, and records the information in our electronic SSI Claim System. Per our recent risk assessment, we are not currently able to make the signature line on this form fillable.

This collection does not currently have a fully public-facing Internet version, as we prioritized other information collections for full electronic conversions. Given that IT Mod programming is an ongoing, dynamic project, we cannot provide specific timelines for when we will be able to make any particular ICR available via Internet web-based application.  We will ultimately convert most existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this may be unconnected to the PRA approval lifecycle. 

In the interim, we evaluated this collection for conversion to a submittable PDF and intend to make this conversion within the next 3-6 years. Once we have the submittable PDF ready for implementation, we will submit a Change Request to OMB for prior approval.

4. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently If we did not use Forms SSA-5062 and SSA-L5063-F3, we would be unable to make accurate determinations of eligibility and SSI payment amounts as required by statute. Because we only collect the information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on July 27, 2021, at

86 FR 40221, and we received no public comments. The 30-day FRN published on September 29, 2021, at 86 FR 54007. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

9. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

9. Justification for Sensitive Questions

This information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

The chart below shows our burden information for this information collection:

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Annual (dollars)*	Average Wait Time in Field Office (minutes) **	Total Annual Opportunity Cost (dollars)**
SSA-5062 (Paper version)	29,026	1	30	14,513	$22.39*	24**	$584,894***
SSA-L5063 (Paper version)	29,026	1	30	14,513	$22.39*	24**	$584,894***
SSA-5062 (SSI claim system)	29,026	1	20	9,675	$22.39*	24**	$476,571***
SSA-L5063 (SSI claim system)	29,026	1	20	9,675	$22.39*	24**	$476,571***
Total	116,104			48,376			$2,122,930***

* We based this figure on average U.S. worker’s hourly wage, as reported by Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes_nat.htm), and on the average DI payments based on SSA's current data (https://www.ssa.gov/legislation/2021FactSheet.pdf).

** We based this figure on the average FY 2024 wait times for field offices, based on SSA’s current management information data.

*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

In addition, OMB’s Office of Information and Regulatory Affairs is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection. OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97 mile driving distance for one-way travel. We depict this on the chart below:

Total Number of Respondents Who Visit a Field Office	Frequency of Response	Average One-Way Travel Time to a Field Office (minutes)	Estimated Total Travel Time to a Field Office (hours)	Total Annual Opportunity Cost for Travel Time (dollars)****
116,104	1	30	58,052	$1,299,784****

****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the 5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.” SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data which shows that the average respondent drives to a field office, rather than using any other mode of transport. SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

NOTE: We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection.  Per our management information data, we believe that the average time in minutes listed in the chart above accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. Based on our current management information data, the current burden information we provided is accurate. The total burden for this ICR is 48,386 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $3,422,714. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

13. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $413,606. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$1,500
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$0*
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$408,686
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0*
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$3,420
Quantifiable IT Costs	Any additional IT costs	$0*
Total		$413,606

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have. It is difficult for us to break down the cost for processing a single form, as field office and State Disability Determination Services staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request When we last cleared this collection in 2018 the burden was 20,420 hours. However, we are currently reporting a burden of 48,376 hours. This change stems from a decrease in the number of responses from 122,528 to 116,104, due to fewer respondents applying for food and shelter assistance. Although the number of responses changed, SSA did not take any actions to cause this change. In addition, we are also increasing the burden per response based on current MI data which shows it takes longer for respondents to learn about the program, gather the information, and complete the information collection. The updated figure represents current MI data.

* Note: The total burden reflected in ROCIS is 152,870, while the burden cited in #12 of the Supporting Statement is 48,376. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, one-way, drive burden. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

16. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirements to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

16. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at

5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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