Statement of Household Expenses and Contributions

The attached MSSICS screens are used to collect information from the SSI claimant or recipient about in-kind support and maintenance. Form SSA-8011-F3 is used to verify with the householder the information on these MSSICS screens which the claimant or recipient has provided. Form SSA-8011-F3 is not a replication of the collection on these MSSICS screens. Form SSA-8011-F3 collects only the information that is needed from the householder to verify the claimant’s or recipient’s in-kind support and maintenance.

MSSICS                    HOUSEHOLD OF ANOTHER                 PAGE 1 OF LOHH

[1-D]                     [2-O]

SSS-SS-SSSS   SSSSS SSSSSSSSSS  PERIOD BEGAN: SS/SS/SSSS  TRANSFER TO:  XXXX

[3-M]

EAT ALL MEALS OUT (Y/N): X

[4-C]
IF NO, BUY FOOD SEPARATE FROM HOUSEHOLD (Y/N): X

[5-C]

WISH TO REBUT PMV (Y/N): X

[6-C]

CLAIMANT/DEEMOR CONTRIBUTE TOWARD HOUSEHOLD EXPENSES (Y/N): X

[7-C]

CLAIMANT MAKES TOKEN CONTRIBUTION (Y/N): X

[8-C]

 DEEMOR MAKES TOKEN CONTRIBUTION (Y/N): X

[9-C]                                            [10-C]

CONTRIBUTION AVERAGE PERIOD FROM (MMYY): PPPP    TO (MMYY): PPPP

    [11-C]

    MONTHLY LOAN AMOUNT:     9999999

    [12-C]

    CLAIMANT'S CONTRIBUTION: 9999999

                                                          [13-O]

                                                          REMARKS (Y): X

MSSICS                   HOUSEHOLD OF ANOTHER                   PAGE 2 OF LOHH

                                [1-D]                        [2-O]

SSS-SS-SSSS   SSSSS SSSSSSSSSS  PERIOD BEGAN: SS/SS/SSSS    TRANSFER TO: XXXX

 [14-M]                                           [15-M]

EXPENSE AVERAGE PERIOD FROM (MMYY): PPPP         TO (MMYY): PPPP

FOR THE PERIOD SHOWN, COLLECT THE FOLLOWING MONTHLY EXPENSES

     [16-C]                    [17-M]

     FOOD: 9999999             MORTGAGE/RENT: PPPPPPP

    [18-C]                                  [19-C]

   PROPERTY INSURANCE: 9999999       PROPERTY TAXES:  9999999

    [20-M]                              [21-M]

    HEATING FUEL: 9999999               ELECTRICITY:  9999999

    [22-M]                 [23-M]

    GAS: 9999999           GARBAGE REMOVAL:   9999999

    [24-M]                             [25-M]

    WATER: 9999999                     SEWER:  9999999

                                [26-D]

                                TOTAL EXPENSES: SSSSSSS

                                [27-D]

                                PRO RATA SHARE: SSSSSSS

                                [28-C]

                                CONTRIBUTION VERIFIED (Y/N):  Y

                                                          [13-O]

                                                          REMARKS (Y): X

MSSICS                  HOUSEHOLD OF ANOTHER                   PAGE 3 OF LOHH

                                [1-D]                      [2-O]

SSS-SS-SSSS   SSSSS SSSSSSSSSS  PERIOD BEGAN: SS/SS/SSSS   TRANSFER TO:  XXXX

EARMARK OPTIONS  1=NOT EARMARKED   2=FOOD  3=SHELTER  4=BOTH FOOD  SHELTER

 [29-D]                [30-M]          [31-M]      [32-D]         [33-D]

 DEEMOR                CONTRIBUTION:   EARMARKED   EXCESS FROM    CLAIMANT'S

                                                   DEEMOR         SHARE

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS         SSSSSSS

 SSSSS SSSSSSSSS         9999999          9            SSSSSSS SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

                       [34-D]

                       TOTAL FOR CLAIMANT: SSSSSSS

                                                           [13-O]

                                                           REMARKS (Y): X

MSSICS                   HOUSEHOLD OF ANOTHER                  PAGE   OF LOHH

                                  [1-D]                     [2-O]

 SSS-SS-SSSS   SSSSS SSSSSSSSSS   PERIOD BEGAN: SS/SS/SSSS  TRANSFER TO: XXXX

                         [34-D]

                         TOTAL FOR CLAIMANT:  SSSSSSS

             [35-M]

             CLAIMANT'S CONTRIBUTION EARMARKED FOR: 9   1=NOT EARMARKED

                                                        2=FOOD ONLY

                                                        3=SHELTER ONLY

                                                        4=BOTH FOOD  SHELTER

         [36-C]                      [37-C]

         IF 4, FOOD AMOUNT: 9999999  SHELTER AMOUNT: 9999999

                   [38-D]                 [39-D]

                   FOOD SHARE: SSSSSSS   SHELTER SHARE: SSSSSSS

                         [40-D]

                         TOTAL ISM FROM HOUSEHOLD: SSSSSSS

                   [41-C]

                   EARMARKED CONTRIBUTION VERIFIED (Y/N):  X

                                                               [13-O]

                                                               REMARKS (Y): X