Addendum to the Supporting Statement for Form SSA-8011-F3
Statement of Household Expenses and Contributions
20 CFR 416.1130–416.1148
OMB No. 0960-0456
Terms of Clearance
The previous OMB clearance stipulated that SSA would explore a revision to this form to make it clear for respondents. Specifically, SSA should consider changes to the explanation of “average” versus fixed monthly expenses and will fix any typographical errors that are identified in the review.
Revision to the Collection Instrument
We have modified Form SSA-8011-F3 to clarify the difference between average and fixed monthly expenses. We reviewed the form to be sure that there are no typographical errors.
The revisions to the form are as follows:
Top of page 1: “Claimant’s/Recipient’s Name” has been changed to
“Claimants/Beneficiary’s Name”
Page 1, Part I:
Changes will be made to the title of Part I and language will be added to the instructions to clarify that we are requesting monthly household expenses.
In the first paragraph of the instructions, the word “average” will be bolded in order to clarify that we are looking to see if they have spent the same, exact amount per month, but expect that the monthly expenses may change.
In the second paragraph of the instructions, we have added language to clarify that these fixed expenses are on a per month basis.
The word “ITEM” has been replaced by “HOUSEHOLD EXPENSE” to clarify that the below list (1-10) are the types of expenses we would like the respondents to track.
In #1 of the list of expenses, the words “Do not” will be italicized to clarify that food bought with food stamps should not be included.