Ssa Printable Form Ssa 5062 Collection and Use of Personal Information Claimant s Statement about Loan of Food or Shelter Form SSA 5062 Sections 205 and 1631 e 1 B of the Social Security Act as amended authorize us to collect this information
If you can t find the form you need or you need help completing a form please call us at 1 800 772 1213 TTY 1 800 325 0778 or contact your local Social Security office and we will help you If you download print and complete a paper form please mail or take it to your local Social Security office or the office that requested it from you Form SSA 5062 Climant Statement About Loan of Food or Shelter Notice This form may be outdated More recent filings and information on OMB 0960 0529 can be found here 2021 09 30 Revision of a currently approved collection Document pdf Download pdf pdf
Ssa Printable Form Ssa 5062
Ssa Printable Form Ssa 5062
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A Form SSA 5062 is the Claimant s Statement About Loan of Food or Shelter Q What is the purpose of Form SSA 5062 A The purpose of Form SSA 5062 is for claimants to report loans of food or shelter received from others Q Who needs to fill out Form SSA 5062 Form Approved Social Security Administration OMB NO 0960 0529 CLAIMANT S STATEMENT ABOUT LOAN OF FOOD OR SHELTER 1 Name and address of person who provided you with food and or shelter 2 Month s in which this person provided you with food and or shelter from to
Form SSA 5062 Claimant s Statement about Loan of Food or Shelter Download form Form SSA 5062 Claimant s Statement about the Loan of Food or Shelter is used to collect information from Supplemental Security Income SSI applicants or beneficiaries regarding the receipt of food or shelter The Social Security Administration SSA 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 suppleme
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6 Remarks I declare under penalty of perjury that I have examined all the information on this form and on any accompanying statements or forms and it is true and correct to the best of my knowledge Signature Date Mailing Address Telephone Number Include area code Form SSA L5063 F3 6 2007 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
REPORT TO UNITED STATES SOCIAL SECURITY ADMINISTRATION IMPORTANT Failure to complete and return this form within Ea days will result in suspension of benefits SIGN AND RETURN THIS FORM IN THE ENCLOSED ENVELOPE SEE INSTRUCTIONS ENCLOSED 1 Print your address here only if it is different from the one shown below number at which you be If you have any questions you may call us toll free at 1 800 772 1213 Monday through Friday from 7 a m to 7 p m If you are deaf or hard of hearing you may call our TTY number 1 800 325 0778 Form SSA 632 Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate
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Collection and Use of Personal Information Claimant s Statement about Loan of Food or Shelter Form SSA 5062 Sections 205 and 1631 e 1 B of the Social Security Act as amended authorize us to collect this information
https://www.ssa.gov/forms/
If you can t find the form you need or you need help completing a form please call us at 1 800 772 1213 TTY 1 800 325 0778 or contact your local Social Security office and we will help you If you download print and complete a paper form please mail or take it to your local Social Security office or the office that requested it from you
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Ssa Printable Form Ssa 5062 - OMB 0960 0529 Form SSA 5062 05 2019 Discontinue Prior Editions Social Security Administration Page 1 of 2 OMB No 0960 0529 CLAIMANT S STATEMENT ABOUT LOAN OF FOOD OR SHELTER The information below refers to Claimant s Name Claimant s SSN Name of Person Making Statement if other than Claimant Relationship to Claimant 1
