Supporting Statement for Form SSA-8011-F3
Statement of Household Expenses and Contributions
20 CFR 416.1130–416.1148
OMB No. 0960-0456
1. Introduction/Authoring Laws and Regulations
Section 1612(a)(2)(A) of the Social Security Act (Act) provides that SSA will reduce the benefits of an eligible recipient who receives support and maintenance in-kind by 33 and 1/3 percent. Section 1631(e)(1)(B) of the Act requires that independent or collateral sources verify the information used to determine eligibility for Supplemental Security Income (SSI) benefits. 20 CFR 416.1130 – 416.1148 of the Code of Federal Regulations provides the procedures and policies for implementing Section 1612(a) (2)(A) of the Act.
Description of Collection
SSA bases eligibility for SSI on the needs of the recipient. In part, we assess need by determining the amount of income a recipient receives. This income includes in-kind support and maintenance in the form of food and shelter owners provide. SSA uses Form SSA-8011-F3 to determine whether the claimant or recipient receives in-kind support and maintenance. This is necessary to determine (1) the claimant or recipient’s eligibility for SSI, and (2) the SSI payment amount. SSA only uses this form in cases where SSA needs the householder’s (head of household) corroboration of in-kind support and maintenance. Claims
representatives collect the information on form SSA-8011-F3 through telephone contact with the respondent, or face-to-face interviews. The claim representative records the information in our electronic MSSICS system. When we use this procedure we do not use a paper Form SSA-8011-F3, and we do not need a signature. The paper SSA-8011-F3 provides information, which could affect SSI eligibility and payment amount. Therefore, the appropriate person, i.e., the householder signs the form; the claim representative documents the information in MSSICS; faxes the form into the appropriate electronic folder; and shreds form. Respondents are householders of homes in which an SSI applicant or recipient resides.
Use of Information Technology to Collect the Information
SSA takes precautions to prevent misuse of Form SSA-8011-F3. Unrestricted availability of this form on the Internet may permit usage of this form by people other than the appropriate person and could result in program abuse. For these reasons, SSA determined that the SSA-8011-F3 is not an appropriate form for implementation on the Internet. In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Intranet version of Form
SSA-8011-F3. Based on our data, we estimate approximately 50% of respondents use the electronic version.
4. Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
6. Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-8011-F3, we would not be able to make accurate determinations of eligibility and benefit amounts due. Because we collect the information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on July 29, 2015, at
80 FR45265, and we received no public comments. The 30-day FRN published on October 22, 2015 at 80 FR 64048. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the development or revision/maintenance of this form.
9. Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
10. Assurances of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. § 1306, 20 CFR 401 and 402, 5 U.S.C. § 552 (Freedom of Information Act), 5 U.S.C. § 552a (Privacy Act of 1974), and OMB Circular No. A-130.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Modality of Completion |
Number of Respondents |
Frequency of Response |
Average Burden Per Response (minutes) |
Estimated Total Annual Burden (hours) |
SSA-8011-F3 |
417,025 |
1 |
15 |
104,256 |
The total burden for this ICR is 104,256 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden to the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $2,085,125. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. Program Changes or Adjustments to the Information Collection Request
The decrease in burden hours stems from a decrease in the number of respondents completing Form SSA-8011-F3.
16. Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provision at 5 CFR 1320.8(b)(3).
B. Collection of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for Form SSA-8011-F3 |
| Author | OPB |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |