Information Collection

Statement of Household Expenses and Contributions - Paper Form

IC 232409 under ICR 202410-0960-010 · OMB 0960-0456.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8011-F3 Statement of Household Expenses and Contributions - Paper Form	Form and Instruction
Form SSA-8011-F3 Statement of Household Expenses and Contributions Statement of Household Expenses and Contributions - Paper Form	Form and Instruction
SSA-8011-F3 Statement of Household Expenses and Contributions SSA-8011-F3 (revised).pdf	Form and Instruction
SSA-8011-F3 Statement of Household Expenses and Contributions SSA-8011-F3 (revised).pdf	Form and Instruction
SSA-8011-F3 (current).pdf Current SSA-8011-F3	IC Document
SSA-8011-F3 (current).pdf Current SSA-8011-F3	IC Document

IC Title:

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
Form and Instruction	SSA-8011-F3				No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	21,000	21,000
Annual IC Time Burden (Hours)	15,750	15,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-8011-F3		10/17/2024

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

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