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	New
Form SSA-5062 Claimant Statement About Loan of Food or Shelter Form	Modified
Support Statement NOV 2006.doc Supporting Statement A	2007-06-06
5063 ADDENDUM TO SUPPORTING STATEMENT NOV 2006.doc Supplementary Document	2006-12-07
5062 ADDENDUM TO SUPPORTING STATEMENT NOV 2006.doc Supplementary Document	2006-12-07

IC Document Collections

IC ID	Document Title	Status
46358	Statement About Food or Shelter Provided to Another Form	New
43703	Claimant Statement About Loan of Food or Shelter Form	Modified

ICR Details

OMB Control No: 0960-0529	ICR Reference No: 200612-0960-006
Status: Historical Active	Previous ICR Reference No: 200606-0960-003
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/07/2007
	Date Received in OIRA: 03/30/2007
Terms of Clearance: OMB approves this collection consistent with the e-mail sent by SSA on 6/6/07. SSA agrees to provide an instrument with standardized format, similar to other SSA forms, upon expiration of this collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2010	36 Months From Approved	07/31/2009
Responses	131,080	0	131,080
Time Burden (Hours)	21,846	0	21,846
Cost Burden (Dollars)	0	0	0

---

Abstract: Forms SSA-5062 and SSA-L5063 are used to obtain statements about food and/or shelter provided to a Supplemental Security Income (SSI) claimant or recipient. SSA uses this information to determine whether food and/or shelter are bona fide loans or should be counted as income for SSI purposes. This determination can affect eligibility for SSI and the amount of SSI benefits payable. The respondents are claimants/recipients for SSI benefits and individuals that provide loans of food or shelter to SSI claimants/recipients.

---

Authorizing Statute(s): US Code: 42 USC 1393 Name of Law: null
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 357	01/04/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 13851	03/23/2007
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
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	SSA-L5063	Statement about Food or Shelter Provided to Another

---

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	131,080	131,080	0	0	0	0
Annual Time Burden (Hours)	21,846	21,846	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: We had initially separated the two IC's and ROCIS which resulted in it showing up as a simultaneous increase and decrease in the burden. There have been no program changes or adjustments in this form, and there is no change in the public reporting burden.

---

Annual Cost to Federal Government: $302,795

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 03/30/2007

---