Information Collection

Statement of Household Expenses and Contributions - SSI Claims System

IC 9338 under ICR 202201-0960-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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
SSI Claim screens for SSA-8011-F3.pdf	Other-SSI Claims System Screen Shot
SSA-8011-F3 - Revised PA Statement.pdf	Other-Revised Privacy Act and PRA St

IC Title:

Statement of Household Expenses and Contributions - SSI Claims System

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SSI Claims System Screen Shot			SSI Claim screens for SSA-8011-F3.pdf		Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act and PRA Statements			SSA-8011-F3 - Revised PA Statement.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 398,759

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	398,759	-18,266	417,025
Annual IC Time Burden (Hours)	299,069	194,813	104,256
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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