The loan agreement must be enforceable under the applicable State Law as an oral or written contract. Check for regional instructions in SI 01120.220.  For a list of States that have specific requirements for handling loans made to minors, see PS 01500.000 Program Requirements – In-Kind Support and Maintenance within PolicyNet “POMS Index”.  For requirements for handling loans made to minors in the state of Oregon, see PS 01415.041.

The loan agreement must be in effect at the time that the ISM is provided to the borrower. A borrower’s obligation for repayment of ISM received must be established at the time the ISM is provided for the ISM to be considered a loan. If the obligation for repayment of ISM is established after the food, shelter, or both are provided, the item received is not a loan of ISM and must be evaluated using normal ISM rules.

EXAMPLE 1: Loan established when ISM provided

Henry applies for Supplemental Security Income (SSI) disability benefits and the facts of their case are:

• •

  03/15/2009 – Henry applies for SSI disability benefits and is using their savings to pay their pro rata share of the household expenses. Henry did not receive any food or shelter from sources outside the household.

• •

  07/31/2009 – Henry and their adult child establish a loan agreement for the food and shelter provided by the adult child when Henry was no longer able to contribute towards household expenses.

• •

  11/05/2009 – Henry submits a signed statement about the loan agreement during the pre-effectuation review contact (PERC) interview stating that they are required to repay the adult child for the food and shelter they received beginning 07/31/2009.

The claims specialist (CS) correctly determines that:

• •

  07/31/2009 - a loan agreement was established as evidenced by the signed statements provided during the PERC interview; and

• •

  if the established agreement meets all of the requirements to be a bona fide loan, the food and shelter received beginning 07/31/2009 is not countable as income because the loan agreement was in effect at the time the son provided the ISM. For bona fide loan of ISM requirements, see SI 00835.482B. (in this section).

REMINDER: The beginning date of the loan is not necessarily the date that the CS records the claimant’s allegations on the Remarks section or Report of Contact page.

EXAMPLE 2: Loan established after ISM provided

Hilda applies for SSI disability benefits and the facts of their case are:

• •

  01/28/2008 – Hilda applies for SSI disability benefits and attests to the information documented on the application within the SSI Claim System's path, which states that the food and shelter they receive from their parent is not a loan.

• •

  12/17/2009 – Hilda’s parent loses their job and can no longer afford to provide the food and shelter. At that point, Hilda and their parent agree that repayment for the food and shelter will be required as of 12/17/2009.

• •

  06/05/2010 – Hilda submits a written statement about the loan agreement during the PERC interview stating that they are required to repay their parent for the food and shelter they received beginning 01/28/2008.

The CS correctly determines that:

• •

  a bona fide loan did not exist at the time of the application (01/28/2008) because no loan agreement was established based on the application statements;

• •

  a loan agreement was established on 12/17/2009 based on case facts;

• •

  the food and shelter received before 12/17/2009 must be evaluated using normal ISM rules because no loan agreement was established at the time the ISM was provided; and

• •

  if the loan agreement meets all of the requirements to be a bona fide loan of ISM, the food and shelter received beginning 12/17/2009 is not countable as income because the loan agreement was in effect at the time the parent provided the ISM.

REMINDER: The date that the claimant signs the statement about a loan of ISM is not necessarily the date the loan was established.

A loan is an advance from a lender that the borrower must repay, with or without interest. For us to consider the ISM as a bona fide loan, the ISM must be given and accepted based on the understanding that it is to be repaid by the borrower.

The obligation to repay must be:

• •

  acknowledged by both the lender and the borrower; and

• •

  unconditional.

IMPORTANT: The borrower and lender must agree that the borrower is expected to repay the lender whether or not the borrower ultimately receives anticipated Title XVI, Title II, Veterans benefits, etc.

EXAMPLE 1: No obligation for repayment

Jane applies for SSI in June 2010. Jane has no income or resources and alleges that their parent provides Jane with food and shelter. Jane states that they feel personally responsible to pay back their parent, but the parent does not expect repayment. The CS determines that a bona fide loan does not exist because Jane and their parent did not have a mutual agreement that Jane must repay the loan. Jane’s statement that they feel personally responsible does not create a legal obligation to repay their parent for the food and shelter they provided.

EXAMPLE 2: Conditional requirement for repayment

Jeff applies for SSI in June 2010. Jeff has no income or resources and alleges that their adult child provides them with food and shelter as a loan. When contacted, the adult child states that Jeff is required to repay them only if Jeff begins to receive their Title XVI benefits.

The CS determines that:

• •

  Jeff does not have an obligation to repay the ISM because the requirement to repay is conditional on their receipt of Title XVI benefits; and therefore

• •

  a bona fide loan does not exist because Jeff has no obligation to repay the ISM.

EXAMPLE 3: Obligation to repay is established

Sarah applies for SSI in April 2010. Sarah alleges that their sibling provides them with food and shelter as a loan. When interviewed by the CS, Sarah and their sibling both state that Sarah must repay the loan of food and shelter whether or not Sarah is found eligible for SSI. In this case, the CS determines that an obligation to repay exists because both parties confirmed that the obligation to repay is not contingent on whether Sarah’s financial circumstances improve.

The loan agreement must include a plan or schedule for repayment, and the borrower's express intent to repay the loan:

• •

  by selling or transferring real or personal property; or

• •

  with current income or anticipated income.

  IMPORTANT: Anticipated income such as Title II, Title XVI, Veterans benefits, etc., may be used to establish a plan for a feasible repayment of the loan. To determine a feasible repayment loan, see SI 00835.482B.5. (in this section).

  CAUTION: Transferring real or personal property for less than its fair market value can cause a period of ineligibility for SSI. For determining the fair market value, see SI 01150.005.

Consider the following factors when preparing or evaluating a repayment plan or schedule:

• •

  Plan should state amount borrowed and repayment terms

The repayment plan or schedule should state the value of the food or shelter, or both, that is being borrowed and the terms of repayment (e.g., how much will be repaid per week or per month, etc.). For a loan of ISM, the value of “shelter” is based on the household expenses listed in SI 00835.465.

• •

  Inside ISM loan amount

The lender (usually the householder) who is providing the food and shelter determines the value of the food or shelter provided. If the lender alleges a monthly dollar value, this is the amount that is borrowed each month. If the loan does not cover the full pro rata share, the individual may be receiving countable ISM for the difference.

• •

  Pro rata share basis for loan amount

If the lender does not allege a monthly loan amount but the CS has computed the borrower's pro rata share of the household expenses, the computed pro rata share is the amount that is borrowed each month as long as the lender agrees.

EXAMPLE: Borrower’s pro rata share basis for loan amount

Jenny lives in the household of Sasha. Jenny states that Sasha provides Jenny with food and shelter under a loan agreement. Sasha is unable to estimate the value of the food and shelter they provide. The CS computes that Jenny's pro rata share of household expenses is $200 per month. Sasha agrees that this amount is reasonable, so the CS determines that $200 is the monthly value of the ISM loan.

• •

  Pro rata share not computed

If the lender does not allege a monthly loan amount and the pro rata share has not been computed, the loan agreement can be bona fide if it stipulates that the borrower is required to repay an amount equal to the pro rata share of household expenses for the period covered by the loan.

• •

  Outside ISM loan amount

If the lender is outside the household and makes a third party vendor payment for food or shelter, the loan amount is the amount of repayment agreed upon by the lender and borrower. The loan amount could be equal to the full amount of the vendor payment or the individual's pro rata share of that amount. If the loan covers several months, the loan amount would be the total of the vendor payments for those months.

EXAMPLE: Lender outside the household

If the outside lender pays $150 toward a utility bill, the loan amount is $150, if the borrower agreed to repay the entire $150. However, if the loan stipulates that the eligible individual is only responsible for their pro rata share of the utility bill and there are two persons in the household, the eligible individual's loan agreement is to repay $75 to the lender.

The plan or schedule for repayment must be feasible. The case facts must show that the individual can repay the loan using their own resources and income. To determine the repayment plan's feasibility, consider only the:

• •

  amount of the loan;

• •

  individual's resources and income (including anticipated income); and

• •

  individual's monthly living expenses.

Do not consider services (e.g., lawn mowing, housekeeping) to determine the repayment plan’s feasibility. Services are not considered as contributions toward the payment of household expenses per SI 00835.480C.

EXAMPLE 1: Feasible loan repayment based on anticipated benefits

Thomas applies for SSI disability benefits and the facts of their case are:

• •

  05/10/2010 - Thomas applies for SSI disability benefits. They allege that their sibling provides them with food and shelter as a loan.

• •

  During the interview, Thomas and their sibling both state that the loan of food and shelter must be repaid whether or not Thomas is found eligible for SSI.

• •

  Prior to completing the SSI application Thomas states if approved they hope to use their SSI benefits to repay the loan.

The CS determines that:

• •

  the obligation to repay was established because both parties confirmed that repayment was not dependent on whether Thomas’s financial situation improved, and

• •

  the repayment plan is feasible because Thomas intends to use anticipated SSI benefits to pay back the loan.

EXAMPLE 2: Prorata share greater than anticipated income

Alex applies for SSI in January 2010 and alleges that they have no income or resources. They live with a sibling, who provides them with food and shelter with a value (pro rata share) of $825 per month. Alex alleges that they have a loan of ISM agreement with their sibling. The repayment plan states that Alex will repay the loan by:

• •

  making monthly payments of $20 from their anticipated monthly $674 SSI check; and

• •

  providing lawn care services valued at $50 per month.

The CS correctly determines:

• •

  Alex's repayment plan is not feasible because their SSI check amount is not sufficient to pay their pro rata share of current household operating expenses ($825);

• •

  The loan is not a bona fide loan of ISM because the repayment plan is not feasible; and

• •

  The value of Alex’s services cannot be considered when determining the plan’s feasibility because services may not be counted as a contribution toward household expenses.

The loan period begins with the date the lender and borrower established the loan agreement. The beginning date of the loan is not necessarily the date the CS records the loan allegations on the Remarks section or Report of Contact page.

REMINDER: All five criteria in SI 00835.482B (in this section) must be met for a bona fide loan of ISM to exist. For posteligibility cases involving a loan of ISM, see SI 00835.482H (in this section).

If the individual alleges that a loan of ISM continues beyond the month of the PERC, treat the allegation as a new loan of ISM that the CS must develop to determine whether the new loan agreement is bona fide.

EXAMPLE: Tracy has a bona fide loan of ISM ending on 06/30/2009, which is the last day of the month that their PERC was conducted. Tracy states that they will not be contributing to the household operating expenses, and that the food and shelter Tracy receives from other household members is a loan that Tracy is obligated to repay. The CS must determine whether the food and shelter received beginning, 07/01/2009 is a new bona fide loan of ISM. For the requirements of a bona fide loan of ISM, see SI 00835.482B. (in this section).

Develop whether a loan of ISM is bona fide at the initial interview or during the PERC. When documenting a loan:

• •

  Ask the individual to provide any documents that support the allegation of a loan of ISM and record them on a Report of Contact page in the SSI Claim System;

• •

  Document the loan allegation and the date that the borrower and lender established the agreement on a Report of Contact page in the SSI Claim System;

• •

  Determine whether the individual has a bona fide loan of ISM using the requirements in SI 00835.482B (in this section);

• •

  Document your bona fide loan determination on a Report of Contact page or under “file documentation notes” on the Household Expenses and Contributions page for SSI Claim cases. For non-MSSICS cases document your determination on an SSA-5002 (Report of Contact) and fax the paper form into the appropriate electronic folder; and

• •

  Destroy the paper form(s) after you document the information electronically.

If the loan of ISM is not bona fide, develop and count ISM using normal ISM rules for the entire period (i.e., back to the application date). Continue with simultaneous development to prepare the claim for the DDS medical decision input.

If the individual has a bona fide loan of ISM, and the individual and the lender allege that the loan covers the full pro rata share, follow these steps:

1. 1. 

   Verify that the loan covers the household expenses for the period covered by the loan;

2. 2. 

   Document the file with the individual’s allegation under the Remarks section on the Househhold Expenses and Contributions page in the SSI Claim System and with the lender’s statement on a Report of Contact page;

3. 3. 

   Determine that the individual is in FLA/A with no ISM starting from the application date;

4. 4. 

   Complete simultaneous development of the claim for the DDS medical decision input; and

5. 5. 

   Set an RT diary to contact the individual within 3 months after they receive the first SSI check to develop the living arrangement.

   NOTE: The CS may need to reset the RT diary if it matures before the DDS disability determination is made.

If the individual and lender do not allege that the bona fide loan covers the full pro rata share, follow these steps to determine whether the individual has received countable ISM:

1. 1. 

   Develop household operating expenses beginning with the month of application. For information about household expenses, see SI 00835.465;

2. 2. 

   Compute the individual's pro rata share. For information on sharing and the pro rata share, see SI 00835.160;

3. 3. 

   Determine whether the loan of ISM (plus any cash contribution) covers the value of the food and shelter received (if not, the difference is countable ISM); and

4. 4. 

   Process the inside ISM development normally in SSI Claim cases:

   • •

     Input the monthly loan amount (plus any additional cash) in the MONTHLY LOAN AMOUNT field on the Household Expenses and Contributions page;

   • •

     Input any cash contribution in the AMOUNT CLAIMANT CONTRIBUTES field. The SSI Claim System correctly computes the ISM and determines whether the one-third reduction rule (VTR) or presumed maximum value rule (PMV) applies. For information about the Household Expenses and Contributions page, see MS INTRANETSSI 010.013 and the Household of Another page, see MS INTRANETSSI 010.014;

   • •

     Complete simultaneous development of the claim so it will be ready for the DDS medical decision input; and

   • •

     Set an RT diary to contact the individual within 3 months after they receive the first SSI check to develop the living arrangement. The CS may need to reset the diary if it matures before the DDS makes a disability determination.

   REMINDER: The VTR (FLA/B) applies only if:

   • •

     the loan amount plus the cash contribution, if any, does not cover the pro rata share of the food and shelter received from within the household, and

   • •

     the applicant receives both food and shelter from within the household of another for the entire month.

   When the VTR does not apply, use the PMV rule to determine ISM, if any. For additional instructions on determining ISM under the PMV rule, see SI 00835.340. For instructions on determining the pro rata share, see SI 00835.020B.25.

When the CS processes a simultaneous development claim to completion based on a bona fide loan of ISM, it is necessary to contact the individual after SSI benefits have started to close out the loan of ISM period and to develop the individual’s new living arrangement period after the loan period ending date. If the CS does not contact the individual, they may receive SSI benefits for many months based only on the loan of ISM. Follow these steps to contact the individual after receipt of SSI benefits has begun:

1. 1. 

   Input an RT diary to contact the individual within 3 months after the estimated first month of SSI payments per the diary instructions in MSOM BUSSR 002.019, “Update Diaries (UDIA);

2. 2. 

   When the diary matures, contact the individual to develop living arrangements and ISM beginning with the month after the month of the first SSI payment. Do not conduct a redetermination if the only reason for contact is to develop the living arrangement;

3. 3. 

   Do full living arrangement development beginning the month after the individual receives the first SSI payment to determine whether the individual’s cash contribution covers the pro rata share of household expenses; and

4. 4. 

   If the contribution does not cover the value of food and shelter the individual receives, determine the amount of ISM and count it beginning with the month after the month of the first SSI payment.

EXAMPLE: Simultaneous development claim with RT diary for re-contact

Alfred files for SSI on 03/12/2009, alleging that they live in their siblings home and receives both food and shelter covered by a loan agreement. The CS completes simultaneous development of the claim on 04/07/2009, and determines that Alfred has a bona fide loan of ISM that is presumed to cover the pro rata share for food and shelter. Alfred’s living arrangement under the loan of ISM is FLA/A with no ISM. The CS adjudicates the claim and inputs an RT diary set for 07/07/2009. At this point, the claim is complete except for the input of the DDS medical determination.

DDS completes its evaluation and inputs a medical allowance on 06/05/2009. Alfred receives their first SSI check on 06/19/2009. When the RT diary matures on 07/07/2009, the CS contacts Alfred to determine their living arrangements beginning 07/01/2009 and to close out the loan of ISM.

On 07/12/2009, the CS interviews Alfred to develop their living arrangements. The CS establishes that Alfred’s pro rata share is $400 per month and that Alfred contributes $300 per month toward the expenses. Based on this information, The SSI Claim System determines that Alfred is in FLA/B and subject to the one-third reduction starting in July 2009 (the month after the month the first SSI payment was received).

If the loan determination has not already been made, determine whether the alleged loan of ISM is bona fide, and document the file. Absent evidence to the contrary, assume that the loan of ISM covers the entire period from the application filing date through the last day of the month of the PERC.

Based on the policy that the loan of ISM applies through the month of the PERC, the new living arrangement period will begin on the first day of the month after the month of the PERC. Use these instructions to establish the new living arrangement period in The SSI Claim System.

For cases that will go from FLA/A with no ISM (during the loan period) to:

• •

  FLA/A with no ISM for the month after the loan ends, input the last day of the PERC month as the date of change on the Living Arrangement Change page;

• •

  FLA/B for the month after the loan ends, input the last day of the PERC month as the date of change on the Living Arrangement Change page; or

• •

  FLA/A with H type ISM income for the month after the loan ends, input the first day of the month after the PERC month as the date of change on the Living Arrangement Change page.

Take the following steps to develop the individual’s anticipated living arrangement as of the month following the month of the PERC:

1. a. 

   Use the Living Arrangement Change page to create a new living arrangement period as explained in SI 00835.482F.2. (in this section);

2. b. 

   On the Household Expenses and Contributions page, enter “N” to indicate there is no loan agreement. This closes out the loan of ISM issue for the new living arrangement period;

3. c. 

   Document the individual’s anticipated living arrangements including the anticipated contribution and the household living expenses on the appropriate SSI Claim page;

4. d. 

   Inform the individual that they are responsible for paying the agreed upon contribution amount starting the month after the month of the PERC. Also inform the individual that they must report to SSA if they do not start contributing the agreed upon amount; and

5. e. 

   Verify with the householder the household expenses and the amount of the agreed upon contribution. Document the householder’s response on a Report of Contact page. When the householder’s verification of the expenses and the agreed upon contribution is received, development of the living arrangement is complete.

EXAMPLE 1: Individual is FLA/ A with no ISM for the loan period and will be FLA/ A with no ISM for the new living arrangement period

Facts of the case:

• •

  01/15/2010 - William filed for SSI, alleging that they have lived in their sibling's home since 11/07/2009, and that they receive food and shelter from their sibling that is covered by a loan agreement.

• •

  07/12/2010 - During the PERC, William establishes that they have a bona fide loan agreement with their sibling to repay their share of the food and shelter, so there is no countable ISM for the period covered by the loan of ISM, which ends the last day of the PERC month.

The CS:

• •

  uses the last day of the PERC month, (07/31/2010) as the date of change on Living Arrangement Change page;

• •

  establishes a new living arrangement period for William for the living arrangement after the loan of ISM ends;

• •

  completes the SSI Claim pages and documents William’s agreed contribution amount;

• •

  documents the householder’s statement verifying the household expenses and the claimant’s allegation;

• •

  determines that William’s expected contribution (as verified by the householder) equals or exceeds the pro rata share; and

• •

  determines that the individual is in FLA:A with no ISM. No further development is needed.

EXAMPLE 2: Individual is FLA/ A with no ISM for the loan period and will be in FLA/ B for the new living arrangement.

Facts of the case:

• •

  01/15/2010 – Kristen filed for SSI, alleging that they have lived in their sibling’s home since 11/07/2009 and that Kristen receives food and shelter from their sibling that is covered by a loan agreement.

• •

  07/12/2010 - During the PERC, Kristen established that they have a bona fide loan agreement with their sibling to repay their share of the food and shelter, so there is no countable ISM for the period covered by the loan of ISM, which ends the last day of the PERC month.

The CS:

• •

  uses the last day of the PERC month (07/31/2010) as the date of change on the Living Arrangement Change page;

• •

  establishes a new living arrangement period for Kristen;

• •

  completes the SSI Claim pages and documents Kristen’s contribution amount;

• •

  documents the householder’s statement verifying the household expenses and the amount that Kristen will be required to contribute toward household expenses (NOTE: In this case, Kristen’s anticipated contribution will be less than the pro rata share of the expenses); and

• •

  determines that Kristen’s contribution does not equal or exceed their pro rata share and that Kristen is in FLA:B as of 08/01/2010. No further development is needed.

Example 3: Individual is in FLA/ A with no ISM for the loan period and will be in FLA/ A with H type income in the new living arrangement

Facts of the case:

• •

  01/15/2010 - Jessie filed for SSI, alleging that they live with their sibling in an apartment for which Jessie has rental liability and that receives food and shelter from their sibling that is covered by a loan agreement.

• •

  07/12/2010 - During the PERC, Jessie established that they have a bona fide loan agreement with their sibling to repay their share of the food and shelter, so there is no countable ISM for the period covered by the loan of ISM, which ends the last day of the PERC month.

The CS:

• •

  uses the last day of the PERC month (07/31/2010) as the date of change on the Living Arrangement Change page;

• •

  establishes a new living arrangement period for Jessie for the living arrangement period after the loan of ISM ends;

• •

  documents the sibling’s statement verifying the household expenses and the amount that Jessie contributes toward household expenses (NOTE: In this case, Jessie’s anticipated contribution will be less than theirpro rata share of the expenses); and

• •

  determines that Jessie’s contribution does not equal or exceed their pro rata share and that Jessie is in FLA/A with H type income as of 08/01/2010. No further development is needed.

Document the loan allegation following SI 00835.482D.1. (in this section).

REMINDER: Use the In-Kind Support and Maintenance page rather than the Household Expenses and Contributions page to document outside ISM. For the In-Kind Support and Maintenance page, see MS INTRANETSSI 010.015.

Determine whether the individual has a bona fide loan of ISM that meets the requirements in SI 00835.482B (in this section) and document the loan determination as explained in SI 00835.482D.2 (in this section) within the SSI Claim System on a Report of Contact page or under “file documentation notes” on the Household Expenses and Contributions page for SSI Claim cases.

For non-MSSICS cases, document the loan determination on an SSA-5002 (Report of Contact) and fax the paper form into the appropriate electronic folder. Destroy the paper form after you document the information electronically.

If no bona fide loan exists, document the loan determination within the SSI Claim System on a Report of Contact page and obtain the amount of the third party's payment(s) for the food or shelter, or both. Record this information within the SSI Claim System on the In-Kind Support and Maintenance page. Determine the amount of ISM received following normal outside ISM development procedures.

For non-MSSICS cases, document the determination on an SSA-5002 and fax the paper form into the appropriate electronic folder. Destroy the paper form after you document the determination electronically.

If the loan is bona fide:

1. a. 

   Determine the actual value of the outside ISM provided to the borrower by the lender as if no loan of ISM existed. For example, if the lender pays a $300 electric bill and there are three members in the household, $100 is countable as ISM to the eligible individual.

2. b. 

   Compare the actual value of the outside ISM provided by the lender with the required loan repayment amount.

3. c. 

   If the loan repayment amount equals or exceeds the actual value of the outside ISM provided by the lender, the borrower receives no outside ISM from the lender. Code the In-Kind Support and Maintenance page as follows:

   • •

     SOURCE NAME: the lender’s name;

   • •

     ISM COUNTABLE:N; and

   • •

     IF NO, REASON: ISM loan.

4. d. 

   If the loan repayment amount is less than the actual value of the outside ISM provided by the lender, the difference is the countable value of the outside ISM received by the borrower. Code the In-Kind Support and Maintenance page as follows:

   • •

     SOURCE NAME: the lender’s name;

   • •

     ISM COUNTABLE: Y; and

   • •

     TYPE OF ISM: 3 – ISM TO ONE.

5. e. 

   Record the amount of countable outside ISM as “ISM only to the claimant” and document the determination on the In-Kind Support and Maintenance page under the “file documentation notes” section. (This input of “ISM only to the claimant” is necessary because the In-Kind Support and Maintenance page is designed to equally apportion outside ISM among the household members.)

Document the borrower’s allegation of the loan of food or shelter or both under the Remarks section on the Household Expenses and Contribution page in the SSI Claim System. Document the lender’s verification of the loan on a Report of Contact page.

REMINDER: The beginning date of the loan is not necessarily the date that the CS records the borrower’s allegations on the Remarks section or Report of Contact page.

If you cannot obtain the information in person or by telephone, you may send the paper form SSA-5062 to the borrower to document allegations of the loan of ISM.

REMINDER: The beginning date of the loan is not necessarily the date that the claimant signed the SSA-5062.

When the FO receives the paper form SSA-5062, document:

• •

  SSI Claim cases by recording the information on a Report of Contact page;

• •

  Non-MSSICS cases by faxing the completed SSA-5062 into the appropriate electronic folder; and

• •

  Do not retain the paper form after you document the issue electronically.

To view this form, go to SSA-5062.

If you cannot obtain the information in person or by telephone, send the paper form SSA-L5063-F3 to the lender to document allegations of the loan of ISM. Form SSA-L5063-F3 has two parts. The first part is a cover letter to the lender that explains why SSA needs the information. The second part is a questionnaire used to document the lender’s statement. REMINDER: The beginning date of the loan is not necessarily the date that the lender signed the SSA-L5063-F3.

When the paper form SSA-L5063-F3 is received in the FO, document:

• •

  SSI Claim cases by recording the information on a Report of Contact page;

• •

  Non-MSSICS cases by faxing the completed SSA-L5063-F3 into the appropriate electronic folder; and

• •

  Do not retain the paper form after you document the issue electronically.

For more information on storing forms electronically refer to GN 00301.322 “Retention of Paper Material After Faxing into Either the eDIB folder or Claims Folder using NDRed”.

To view this form, go to SSA-L5063–F3.

During telephone interviews the CS is responsible for reading the following summarized privacy act statement before documenting information obtained verbally from the SSA-L5062 and the SSA-L5063-F3 within a case file:

Sections 1612(a) and 1631(e) of the Social Security Act allows us to collect your information, which we will use to determine your Supplemental Security Income payment amount. Providing this information is voluntary, but not providing the information could affect your Supplemental Security Income monthly federal benefit payment. We may disclose your information as law permits, including to employers, our contractors, and others listed in routine uses in System of Records Notice 60-0089 and 60-0103; available at www.ssa.gov/privacy. Your information may also be used in computer matching programs to establish or verify eligibility for Federal benefit programs and debts under these programs.

After reading the summarized statement the CS is responsible for mailing the form with the complete privacy act statement to the recipient, or directing the recipient to www.ssa.gov/privacy to review the full statement electronically. Document on a Report of Contact the following statement, Oral Summarized Privacy Act Statement Read and include the recipient's name or the lender's name (whichever applies) and the date of the action. In addition, document if you mailed the privacy act statement or directed the recipient to the website to review an electronic version.