Statement of Household Expenses and Contributions - SSI Claims System

Statement of Household Expenses and Contributions

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.