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⚠️ Notice: This information collection may be referencing outdated material.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:

Documents and Forms

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:

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

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 %

	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

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.