Form SSA-8011-F3 Statement of Household Expenses and Contributions

FORM APPROVED
OMB No. 0960-0456

SOCIAL SECURITY ADMINISTRATION

STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS
SOCIAL SECURITY NUMBER

CLAIMANT'S / BENEFICIARY'S NAME
NAME OF SPOUSE OR PARENT(S) OF INDIVIDUAL NAMED ABOVE
NAME OF PERSON MAKING THIS STATEMENT

The questions on this form are divided into four sections. Answer the questions where we have checked
the block. Then sign the form and return to Social Security.
PART I - MONTHLY HOUSEHOLD EXPENSES
For household expenses that change from month to month, show the average monthly amount of money
your household has spent per month for the period
through
.
For the household expenses that are usually the same from month to month (like rent), show the amount
your household spent per month as of
.
Write "0" under amount if your household has not spent any money for one of the expenses.
MONTHLY
AMOUNT SPENT

HOUSEHOLD EXPENSES
1. Food (Do not include food bought with food stamps.)

$

2. Rent or Mortgage Payment

$

3. Property Insurance (if not included in mortgage payment and if required by mortgage holder)

$

4. Real property taxes (if not included in mortgage payment). Subtract any rebate or credit.

$

5. Electricity

$

6. Gas

$

7. Heating fuel (wood, coal, oil, kerosene, etc.)

$

8. Water

$

9. Sewerage

$

10. Garbage Removal

$

PART II-CONTRIBUTIONS TO HOUSEHOLD EXPENSES
In the spaces below, show the amount of money the person(s) named gave for the household expenses
listed in Part I. Provide your answer for the blocks we have checked.
AVERAGE MONTHLY AMOUNT GIVEN

NAME

Form SSA-8011-F3 (12-2012)

from

EF (12-2012)

AMOUNT GIVEN

through

In

$

$

$

$

$

$
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PART III - OTHER ARRANGEMENTS
1.

Do(es)
meal during the month some where else?

2.

Do(es)
his/her/their own food with his/her/their own money?

3.

Do(es)
amount just for household food?

eat every

buy all

pay a certain

*If "Yes" how much each month?
NAME

$

NAME

$

NAME

$

4.

YES

NO

YES

NO

YES *

NO

AMOUNT

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

YES *

*If "Yes" how much each month?
NAME

$

NAME

$

NAME

$

NO

AMOUNT

PART IV-REMARKS-Use this space for any additional explanations.

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
Your Signature (First name, middle initial, last name)

Date (Month, Day, Year)

SIGN
HERE

Day Time Telephone No.
(Include Area Code)

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

2. SIGNATURE OF WITNESS

ADDRESS (Number and Street)

ADDRESS (Number and Street)

CITY,STATE, AND ZIP CODE

CITY,STATE, AND ZIP CODE

Form SSA-8011-F3 (12-2012)

EF (12-2012)

Page 2

Privacy Act Statement
Collection and Use of Personal Information

See Revised
Privacy Act and
Section 1631(e)(1)(A) of the Social Security Act, as amended, authorizes us to collect this information. We will use
PRA Statement
the information in determining your eligibility for benefit payments and to help us decide if additional information is
needed.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could
prevent us from making an accurate and timely decision, or could result in the loss of benefits.
We rarely use the information you supply for any purpose other than for determining entitlement to benefit payments.
We may also disclose information to another person or to another agency in accordance with approved routine uses,
which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or
coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and
local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement
of Social Security programs (e.g., to the Bureau of the Census).
We may also use the information you provide in computer matching programs. Matching programs compare our records
with records kept by other Federal, State, or local government agencies. Information from these matching programs
can be used to establish or verify a person's eligibility for federally-funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records Notices entitled, Claims
Folders Systems, 60-0089, and Supplemental Security Income Record and Special Veterans Benefits, 60-0103. These
notices, additional information regarding this form, and information regarding our programs and systems, are available
on-line at www.socialsecurity.gov or at your local Social Security office.

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 OR BRING 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 (TTY 1-800-325-0778). You may
send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
Form SSA-8011-F3 (12-2012)

EF (12-2012)

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SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 1612(a)(2)(A) and 1631(e)(1)(A)-(B) of the Social Security Act, as amended, allow us to
collect this information. We will use the information you provide to determine your eligibility
for benefits and benefit payment amounts.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information could prevent us from making an accurate decision on your claim and could result
in the loss of benefits.
We rarely use the information you supply for any purpose other than what we state above.
However, we may use the information for the administration of our programs including sharing
information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census
and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notices, 60-0089, entitled Claims Folders Systems, and 600103, entitled Supplemental Security Income Record and Special Veterans Benefits. Additional
information about these and other system of records notices and our programs is available
from our Internet website at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 (OMB) control number. We estimate that it will take about
15 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.