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

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nuveu
OMB NO. 0960-0456

SOCIAL SECURITY ADMINISTRATION

STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS
CLAIMANT'S/R€CW€MSBENEFICIARY'S NAME

SOCIAL SECURITY NUMBER
I

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 I-

MONTHLY HOUSEHOLD EXPENSES

For household expenses that change from month to month, &how the average /BOLD "averane") monthly amount of money
the period t h r o u g h
your household has spent per month of-r
W E o r the household expenses that are usually the same from month to month (like rent), show the amount your household
w s p e n t per month a s p f

-

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

I

W H O U S E H O L D EXPENSES

MONTHLY
AMOUNT SPENT

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

$

n PART II-CONTRIBUTIONS

TOHOUSEHOLD EXPENSES

In the spaces below, show the amount of money the person(s) named gave for the household expenses listed in Part I.
Provide your answer for the blocks we have checked
NAME

FORM SSA-8011

AMOUNT GIVEN

AVERAGE MONTHLY AMOUNT GIVEN
from

In

through

$

$

$

$

$

$
Page 1

PART Ill-OTHER

ARRANGEMENTS

1.

Do(es)
during the month some where else?

eat every meal

2.

Do(es)
own food with hislherltheir own money?

buy all hislherltheir

3.

Do(es)
amount just for household food ?

pay a certain

[7 YES

NO

YES

NO

YES'

NO

I

*If "ves" how much each month?
NAME

AMOUNT

NAME

4.

Do(es)
for the h

pay a certain amount
o

u

[7 YES'

a

'If "yes" how much each month?
NAME

NO

AMOUNT

$

NAME

$

NAME

$

PART IV-REMARKS-Use

this space for any additional explanations.

I know that anyone who makes or causes to be made a false statement or representation of material fact for use in
determining a right to payment under the Social Security Act commits a crime punishable under Federal or State law or
both. I affirm that all information I have given in this document is true.
Your signature (first name, middle initial, last name)

SIGN
HERE

SIGNATL RF
Date (Month, Day, Year)

+

Day Time Telephone No.
(include Area Code)

WITNFSSFS
If you have signed by mark (X), two witnesses to the signing who know you must sign below giving their full addresses.
1.

SIGNATURE OF WITNESS

2.

SIGNATURE OF WITNESS

ADDRESS (Number and Street)

ADDRESS (Number and Street)

CITY, STATE, AND ZIP CODE

CITY, STATE, AND ZIP CODE

FORM SSA-8011

Page 2

The Paperwork Reduction
accordance with the
We may not conduct
unless it displays a

collection is in
Act of 1995.

. This includes the time it will

PRIVACY A

C

T

I

P

P NOTICE

Section 1634(e)(1) of the Social Security Act authorizes us to collect the information requested on this
form to decide if the individual(s) named can receive Supplemental Security Income (SSI) payments
from us and, if so, how much. The individual or the individual's representative has given permission to
us to obtain this information. You do not have to give us this information but if you do not, it may
adversely affect the individual's eligibility for or the amount of SSI.
The information on this form may be disclosed without your consent ( I ) to comply with a Federal law
requiring the release of information from our records, or (2) to an agency needing this information to
decide if the individual(s) named is (are) eligible for a health or income-maintenance program such as
SSI State supplemental payments, food stamps, Medicaid, energy assistance, or unemployment
insurance. Information about other disclosures of this information are published in the Federal Register
and is available in local Social Security Offices.
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies
may use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide to us may be used or given out
are available in Social Security Offices. If you want to learn more about this, contact any Social Security
Office.

FORM SSA-8011 iWb)

Page 3

'U.S. Government Printing Office: 1998: - 433-335180182

Thefollowing revised PRA Statement will be inserted into theform at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 8 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 control number. We estimate that it will take about 15
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 2 1235-6401. Send & comments relating to our time estimate to this
address, not the completed form.