Supporting Statement for Form SSA-8011-F3
Statement of Household Expenses and Contributions
20 CFR 416.1130–416.1148
OMB No. 0960-0456
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)(A)-(B) of the Act requires independent or collateral sources to verify the information used to determine eligibility for Supplemental Security Income (SSI) benefits. Sections 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’s 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. The SSA‑8011-F3 provides information, which could affect SSI eligibility and payment amount. The claim specialist collects the information on Form SSA-8011-F3 through telephone contact with the respondent, or through face‑to-face interviews. The claims specialist records the information in our electronic SSI Claims System. When we use this procedure we do not use a paper Form SSA-8011-F3, and we do not need a wet signature, rather we require verbal attestation. However, when we use a paper form, we ensure the appropriate person, i.e., the householder signs the form, and then the claims specialist documents the information in the SSI Claims System; 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 through our SSI Claims System. Based on our data, we estimate approximately 50% of respondents use the electronic version.
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.
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 payment 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 August 6, 2018, at 83 FR 38441, and we received no public comments. The 30-day FRN published on October 15, 2018 at 83 FR 52042. If we receive any comments in response to this Notice, we will forward them to OMB.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
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
Per our current management information data, approximately 425,258 respondents take 15 minutes each to complete form SSA-8011-F3 each year. We estimate approximately 417,205 are completed using the SSI Claims System, and 8,233 are downloaded and completed using the paper form. Accordingly, the burden is 106,314 hours, as per the chart below:
Modality of Completion |
Number of Respondents |
Frequency of Response |
Average Burden Per Response (minutes) |
Estimated Total Annual Burden (hours) |
SSA-8011-F3 (Paper Version) |
8,233 |
1 |
15 |
2,058 |
SSA-8011-F3 (SSI Claim System) |
417,025 |
1 |
15 |
104,256 |
Total |
425,258 |
|
|
106,314 |
We based these figures on the use within the SSI Claims System, and the number of downloaded and completed forms we receive (for cases outside the SSI Claims System). 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 $2,534,538. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time; and (3) systems development, updating, and maintenance costs.
Program Changes or Adjustments to the Information Collection Request
When we last cleared this IC in 2015, the burden was 104,256 hours. However, we are currently reporting a burden of 106,314 hours. This increase stems from an increase in the number of responses from 417,025 to 425,258. In addition, we also separated out the paper modality from the SSI Claims System modality. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change.
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).
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 | 2021-01-20 |