Current Form SSA-8011-F3

FORM APPROVED
OM0 No. OS6GWtr6

SOCIAL SECURITY ADMINISTRATION

STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS
CLAIMANT'S I RECIPIENT'S NAME

SOCIAL SECURITY NUMBER

NAME OF SPOUSE OR PARENT(S1 OF IND1VIDUAL NAMED ABOVE
NAME OF PERSON MAKING THIS STATEMENT
The questions on this form are divided into four sections, Answer the questions w hare we have checked
the block. Then sign the form and return to Social Security,

PART I - HOUSEHOLD EXPENSES
Show the average monthly amount of money your household has spent on the expenses listed for the
period
through

But for expenses that are usually the same from month to month (like rent), show the amount your
household paid as of
Write "Om under amount if your household has not spent any money for one of the expenses.
MONTHLY
AMOUNT SPENT

ITEM
1. Food {Do not Include f o d bought with food stamps.)

$

2. R e n t or Mortgage Payment

$

3. Property Insurance (if not Included in mortgage payment and If requlred by mortgage holder)

$

4, Real property taxes (ifwt included in mortgage payment). Subtract any rebate or credit.
5. Electricity

$

6. Gas

$

7. Heating fuel (wood, coal, 011, kerosene, etc.)
--

8. Water

S

9. Sewerage
- -

10. Garbaw Removal

In the spaces below, show the amount of money the person(s1 names gave for the household expenses
listed in Part I. Provide your answer for the blocks we have checked.
NAME

Form SSA-801 IS3 (8-1989) EF (07-2003)

AMOUNT GIVEN

AVERAOE MONTHLY AMOUNT GIVEN

from

through

In

$

S

$

$

$

$

-

PART 111 OTHER ARRANGEMEMTS
1.

Doles)
meal during the month some where else?

2.

Do(es1
hislherhhelr own food with hiismernheir own money?

wt every

NO

buy all

DoIes)

3.

[7 YES

pay a certaln

amount just for household food?

AMOUNT

*If "Yesa how much each month?
NAME

4.

8

pay a certain
Do(es)
amount for the household shelter expenses (The expenses other than food)?

*If "Yes" how much each month?
NAME

YES

+

NO

AMOUNT

$

NAME
NAME

PART IV-REMARKS-Use ttrls space for any additional explanation$.
Total Household Expenses: 8

I know that anyone who makes or causes to be made a false statement or representation of material fact
for use in determining a right to payment under the Soclal Security Act commits n crime punishable under
Federal or State law or both, 1 affirm that all information 1 have given in this document is true.
SIGNATURE

,

Your Signatwe [First name, middle initial, last name)

SIGN
HERE

l~ate
(Month, Day, Year)

l ~ aT
y i m Telephone No.

~lnc/uds~ r s codel
s

WITNESSES

If you have signed by mark (X), two witnesses to the signing who know you must sign below giving their
full addrmses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS

1

ADDRESS (Number,and Street)

IAODRESS (Number and Street]

CITY,STATE, AND ZIP CODE

ICITY,STATE, AHO ZIP CODE

I

I

Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S,C. § 3507, as amended by Section 2 of the Paperwork
Reduction -Act of 1995. You do not need to answer these questions unless we
display a valid Office of Management and Budget control number. We estimate that
it will take about 15 minutes to read the instructions, gather the facts, and answer
the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213. You may send
comments on our t h e estimate above to: SSA, 1338 Annex Building, Baltimore,
MD 21235-000L Send d y comments relating to our tihe estimate to this
address, not the completed form.
PRIVACY ACT NOTICE
P

Section 1631(e)(l) of the Social Security Act authorizes us t o collect the
information requested on this form to decide if the individual(s1 named can receive
Supplemental Security Income (SSI) payments from us and, if so, Row much, The
individual or the individual's representative has given permission t o us to obtain this
information. You do not have to give us this informaiton but if you do not, it may
adversely affect the individual's eligibility for or amount of SSI.
The information collected on this form may be disclosed without your consent (1) to
comply with a Federal law requiring the release of information from our records, or
(2) to an agency needing this information to decide if the individual(s) named is (are)
eligible for a health or income-maintenance program such as SSI State
P
supplementary payments, food stamps, Medicaid, energy assistance, or
unemployment insurance. Information about other disclosures of this information is
published in the Federal Register and is available in local Social Security offices.
We may also use the information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove
that a person qualifies for benefits paid by the Federal government. The law allows
us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be
used or given out are available in Social Security offices, If you want to learn more
about this, contact any Social Security office.

Form SSA-801143 (8-1989) EF (07-2003)

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U.S. OWERNMENT PRINTING OFFICE:

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