Statement of Household Expenses and Contributions

OMB 0960-0456

OMB 0960-0456

SSA bases eligibility for SSI on the needs of the recipient. In part, we asses need by determining the amount of income a recipient receives. This income includes in-kind support and maintenance in the form of food and shelter provided by other persons. SSA uses Form SSA-8011-F3 to determine if the claimant or recipient receives in-kind support and maintenance. This is necessary to determine (1) the claimant or recipient's eligibility for SSI and (2) the SSI payment amount. SSA only uses this form in cases where SSA needs the householder's (head of household) corroboration of in-kind support and maintenance. Respondents are householders of homes in which an SSI applicant or recipient resides.

The latest form for Statement of Household Expenses and Contributions expires 2022-02-28 and can be found here.

OMB Details

Statement of Household Expenses and Contributions - SSI Claims System

Federal Enterprise Architecture: Income Security - General Retirement and Disability


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