Statement of Household Expenses and Contributions - Paper Form

Statement of Household Expenses and Contributions

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0456 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-8011-F3 Statement of Household Expenses and Contributions - Paper Form Form and Instruction
Revised PA and PRA Statement - 0456.pdf Other-Revised Privacy Act and PRA St
SSA-8011-F3 Statement of Household Expenses and Contributions SSA-8011-F3 - Revised Version.pdf Form and Instruction
SSA-8011-F3 - Current version.pdf Current SSA-8011-F3 IC Document

Information Collection (IC) Details

IC Title:	Statement of Household Expenses and Contributions - Paper Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1130 - 416.1148

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-8011-F3	Statement of Household Expenses and Contributions	SSA-8011-F3 - Revised Version.pdf		No		Fillable Printable
Other-Revised Privacy Act and PRA Statements			Revised PA and PRA Statement - 0456.pdf		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,233	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8,233	8,233
Annual IC Time Burden (Hours)	2,058	2,058
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-8011-F3	SSA-8011-F3 - Current version.pdf	11/14/2018

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