Statement of Household Expenses and Contributions - Paper Form

Statement of Household Expenses and Contributions

Documents and Forms

Document Name Document Type
Form SSA-8011-F3 Statement of Household Expenses and Contributions - Paper Form Form and Instruction
SSA-8011-F3 - Revised PA Statement.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: Modified

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			SSA-8011-F3 - Revised PA Statement.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: 21,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	21,000	12,767	8,233
Annual IC Time Burden (Hours)	15,750	13,692	2,058
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-8011-F3	SSA-8011-F3 - Current Version.pdf	01/13/2022

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