Information Collection

0960-0456 SSA-8011 (Paper Form)

IC 262447 under ICR 202309-0960-006 · OMB 0960-0835.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0835 can be found here:

2024-04-19 - New collection (Request for a new OMB Control Number)

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8011 0960-0456 SSA-8011 (Paper Form)	Form and Instruction
SSA-8011 Statement of Household Expense and Contributions SSA-8011.pdf www.ssa.gov	Form and Instruction
SSA-8011 Statement of Household Expense and Contributions SSA-8011.pdf www.ssa.gov	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

0960-0456 SSA-8011 (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 416.1100 20 CFR 416.1102 20 CFR 416.1104 20 CFR 416.1110 20 CFR 416.1120 20 CFR 416.1130-416.1148 20 CFR 416.1160-416.1161 20 CFR 416.1201

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	Statement of Household Expense and Contributions	SSA-8011.pdf	www.ssa.gov	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,500	10,500
Annual IC Time Burden (Hours)	6,300	6,300
Annual IC Cost Burden (Dollars)	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.