Statement of Household Expenses and Contributions

SSA bases eligibility for Supplemental Security Income (SSI) on the needs of the recipient. In part, we assess need through determining the amount of income a recipient receives. This income includes in-kind support and maintenance in the form of food and shelter home owners provide. SSA uses Form SSA-8011-F3, Statement of Household Expenses and Contributions, to determine whether the claimant or recipient receives in-kind support and maintenance. This is necessary to determine: (1) The claimant’s 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. The SSA-8011-F3 provides information, which could affect SSI eligibility and payment amount. An SSA claims specialist collects the information on Form SSA-8011-F3 through telephone contact with the respondents, or through face-to-face interviews. The claims specialist records the information in our electronic SSI Claims System. When we use this procedure, we do not use a paper Form SSA-8011-F3, and we do not require a wet signature, rather we request verbal attestation. However, for those few instances when we use a paper form, we ensure the appropriate person, i.e., the householder, signs the form, and then the claims specialist documents the information in the SSI Claims System; faxes the form into the appropriate electronic folder; and shreds the form. Respondents are householders of homes in which an SSI applicant or recipient resides. We are submitting this Non-Substantive Change Request to remove the signature requirement and replacing the Penalty of Perjury Statement with a Penalty of Perjury Warning.

The latest form for Statement of Household Expenses and Contributions expires 2026-12-31 and is listed under ICR 202410-0960-010.

Statement of Household Expenses and Contributions - SSI Claims System

Federal Enterprise Architecture: Income Security - General Retirement and Disability