Information Collection

Statement of Household Expenses and Contributions

IC 9338 under ICR 201209-0960-010 · OMB 0960-0456.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0456 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8011-F3 Statement of Household Expenses and Contributions	Form
MSSICS Screen Shots for 8011 09-2012.doc	Other-MSSICS
SSA-8011-F3 Statement of Household Expenses and Contributions SSA-8011-F3 (revised).pdf	Form
SSA-8011-F3 (current).pdf Statement of Household Expenses and Contributions	IC Document

IC Title:

Statement of Household Expenses and Contributions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1130-416.1148

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-8011-F3	Statement of Household Expenses and Contributions	SSA-8011-F3 (revised).pdf		No		Paper Only
Other-MSSICS			MSSICS Screen Shots for 8011 09-2012.doc		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 428,100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	428,100	28,100	400,000
Annual IC Time Burden (Hours)	107,025	7,025	100,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Statement of Household Expenses and Contributions	SSA-8011-F3 (current).pdf	10/15/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.