Form SSA-8011-F3 Statement of Household Expenses and Contributions

Form SSA-8011-F3 (XX-20XX) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 3
OMB No. 0960-0456

STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS
CLAIMANT'S / BENEFICIARY'S NAME

SOCIAL SECURITY NUMBER

NAME OF SPOUSE OR PARENT(S) OF INDIVIDUAL NAMED ABOVE

NAME OF PERSON MAKING THIS STATEMENT

The questions on this form are divided into four sections. Answer the questions where we have checked the block. Then sign the
form and return to Social Security.
PART 1 - MONTHLY HOUSEHOLD EXPENSES
For household expenses that change from month to month, show the average monthly amount of money your household has
spent per month for the period

through

.

For the household expenses that are usually the same from month to month (like rent), show the amount your household spent
per month as of

.

Write "0" under amount if your household has not spent any money for one of the expenses.
MONTHLY
TOTAL SPENT

HOUSEHOLD EXPENSES
1. Food (Do not include food bought with food stamps.)
2. Rent or Mortgage Payment
3. Property Insurance (if not included in mortgage payment and if required by mortgage holder)
4. Real property taxes (if not included in mortgage payment). Subtract any rebate or credit.
5. Electricity
6. Gas
7. Heating fuel (wood, coal, oil, kerosene, etc.)
8. Water
9. Sewerage
10. Garbage Removal

$
$
$
$
$
$
$
$
$
$

PART 2 - CONTRIBUTIONS TO HOUSEHOLD EXPENSES
In the spaces below, show the amount of money the person(s) named gave for the household expenses listed in Part 1. Provide
your answer for the blocks we have checked.
AVERAGE MONTHLY AMOUNT GIVEN
AMOUNT GIVEN
NAME
from
through
in
$

$

$

$

$

$

Form SSA-8011-F3 (XX-20XX) UF

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PART 3 - OTHER ARRANGEMENTS
1.

Do(es)

eat every meal during the month some where else?

YES

NO

2.

Do(es)

buy all his/her/their own food with his/her/their
own money?

YES

NO

3.

Do(es)

pay a certain amount just for household food?

YES*

NO

*If "Yes" how much each month?

AMOUNT

Name

$

Name

$

Name

4.

Do(es)

$
pay a certain amount for the household shelter
expenses (the expenses other than food)?

YES*

*If "Yes" how much each month?

NO

AMOUNT

Name

$

Name

$

Name

$

PART 4 - REMARKS-Use this space for any additional explanations.

Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in
determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent
to affect an initial or continued right to payment, or submit or causes to be submitted any false statement or document
knowing the same to contain any misrepresentation of material fact, comments a crime punishable under federal law by
fine, imprisonment, or both, and may be subject to administrative sanctions.
Name of Person Completing the Form (Print)

Mailing Address

Date

Telephone Number (Include area code)

Form SSA-8011-F3 (XX-20XX) UF

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Privacy Act Statement
Collection and Use of Personal Information
Sections 1612(a)(2) and 1631(e)(1) of the Social Security Act, as amended, allow us to collect this information, which
we will use to verify household expenses and contributions of the named Supplemental Security Income (SSI)
claimant or recipient to determine eligibility and benefit payment amount. Providing this information is voluntary, but
not providing all or part of the information may prevent an accurate and timely decision on benefit eligibility and
benefit payment amount or could result in the loss of benefits of the named claimant. As law permits, we may use
and share the information you submit, including with other Federal agencies, contractors, and others, as outlined in
the routine uses within System of Records Notices (SORN) 60-0089, 60-0103, and 60-0320, available at
www.ssa.gov/privacy. The information you submit may also be used in computer matching programs to establish or
verify eligibility for Federal benefit programs and to recoup debts under these programs.

Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to
answer these questions unless we display a valid Office of Management and Budget (OMB) control number.
We estimate that it will take about 2 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401.