Information Collection

Statement of Household Expenses and Contributions - Paper Form

IC 232409 under ICR 201807-0960-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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 - 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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.