Addendum -0960-0454

Addendum to Supporting Statement for Form SSA-L5061

Letter to Landlord Requesting Rental Information

20 CFR 416.1130(b)

OMB No. 0960-0454

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

• Change #1: We are revising the PRA statement on this form.

Justification #1: We are revising the PRA statement to reflect our current boilerplate language.  The current language, which dates back to the last reprint of the form, is now outdated.

• Change #2: We are revising the Privacy Act statement on this form.

Justification #2: SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on this form.

• Justification #3: We are revising the language on the letter of the SSA-L5061

• New Language: [Name of Individual] has recently applied for or currently receives Supplemental Security Income (SSI) with the Social Security Administration. Part of our requirements when evaluating an SSI application or existing SSI beneficiary is to assess the income sources for the individual, which can include “unearned” income such as a rental subsidy. If we determine the individual receives rental subsidy, we may change the individual’s SSI payment or determine they are no longer eligible for SSI payments. The above-named individual or their representative has identified you as the person they pay for their residence and has given us permission to request potentially relevant information from you.

This form is requesting information that will help inform us as to who is responsible for payment of rent at the listed residence. Your responses will help us understand whether the above individual is receiving a rental subsidy.

The information provided will be maintained as a part of the individual’s record with us. In addition, the information provided may be given out (such as to other Federal or state agencies) if required by Federal law without us seeking additional consent. Similarly, we may provide the information to a Federal or state agency that needs it to help decide whether the individual is eligible for other health or income assistance programs such as SSI State supplementary payments, food stamps, Medicaid, energy assistance, or unemployment insurance. Please contact the listed Social Security Office if you have additional questions about our information sharing policies.

[Continue with rest of letter as-is]

Justification #3: We are revising the language for clarity.