Statement of Household Expenses and Contributions

ICR 202201-0960-007

OMB: 0960-0456

Federal Form Document

Forms and Documents
Form and Instruction
Supplementary Document
Supporting Statement A
ICR Details
0960-0456 202201-0960-007
Received in OIRA 201807-0960-009
Statement of Household Expenses and Contributions
Revision of a currently approved collection   No
Regular 01/13/2022
  Requested Previously Approved
36 Months From Approved 02/28/2022
419,759 425,258
314,819 106,314
0 0

SSA bases eligibility for Supplemental Security Income (SSI) on the needs of the recipient. In part, we assess need through determining the amount of income a recipient receives. This income includes in-kind support and maintenance in the form of food and shelter home owners provide. SSA uses Form SSA-8011-F3, Statement of Household Expenses and Contributions, 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. An SSA claims specialist collects the information on Form SSA-8011-F3 through telephone contact with the respondents, 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 require a wet signature, rather we request verbal attestation. However, for those few instances 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 the form. Respondents are householders of homes in which an SSI applicant or recipient resides.

US Code: 42 USC 1382a Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act

Not associated with rulemaking

  86 FR 56746 10/12/2021
87 FR 139 01/03/2022

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 419,759 425,258 0 0 -5,499 0
Annual Time Burden (Hours) 314,819 106,314 0 0 208,505 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
When we last cleared this IC in 2018, the burden was 106,314 hours. However, we are currently reporting a burden of 104,940 hours. This decrease stems from an decrease in the number of responses from 425,258 to 419,759. 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. Finally, as per OMB’s request, we included the 30-minute travel time to a field office in our burden calculations, which also increased the burden.

Faye Lipsky 410 965-8783 [email protected]


On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

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