Information Collection

Statement of Household Expenses and Contributions

IC 9338 under ICR 201507-0960-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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 SSA-8011-F3 (current)	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: 417,025

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	417,025	-11,075	428,100
Annual IC Time Burden (Hours)	104,256	-2,769	107,025
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-8011-F3 (current)	SSA-8011-F3(current).pdf	10/27/2015

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