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

FORM APPROVED
OMB No. 0960-0456

SOCIAL SECURITY ADMINISTRATION

STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS
SOCIAL SECURITY NUMBER

CLAIMANT'S / BENEFICIARY'S NAME
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, show the average monthly amount of money
your household has spent per month for the period
through

.

For the household expenses that are usually the same from month to month (like rent), show the amount
your household spent per month as of
.
Write "0" under amount if your household has not spent any money for one of the expenses.
MONTHLY
AMOUNT SPENT

HOUSEHOLD EXPENSES
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

$

PART II-CONTRIBUTIONS TO HOUSEHOLD EXPENSES
In the spaces below, show the amount of money the person(s) names gave for the household expenses
listed in Part I. Provide your answer for the blocks we have checked.

Form SSA-8011-F3 (07-2007)

AMOUNT GIVEN

AVERAGE MONTHLY AMOUNT GIVEN

NAME

from

EF (07-2007)

In

through

$

$

$

$

$

$
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PART III - OTHER ARRANGEMENTS
1.

Do(es)
meal during the month some where else?

2.

Do(es)
his/her/their own food with his/her/their own money?

3.

Do(es)
amount just for household food?

eat every

buy all

pay a certain

*If "Yes" how much each month?
NAME

$

NAME

$

NAME

$

4.

YES

NO

YES

NO

YES *

NO

AMOUNT

Do(es)
pay a certain
amount for the household shelter expenses (The expenses other than food)?

*If "Yes" how much each month?
NAME

YES *

NO

AMOUNT

$

NAME

$

NAME

$

PART IV-REMARKS-Use this space for any additional explanations.
Total Household Expenses: $

I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge.
SIGNATURE
Your Signature (First name, middle initial, last name)

Date (Month, Day, Year)

SIGN
HERE

Day Time Telephone No.
(Include Area Code)

WITNESSES
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-F3 (07-2007)

EF (07-2007)

Page 2

PRIVACY ACT NOTICE

See Revised Privacy Act
Statement

Section 1631(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 amount of SSI.
The information collected on this form may be disclosed without your consent (1) 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
supplementary payments, food stamps, Medicaid, energy assistance, or
unemployment insurance. Information about other disclosures of this information is
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 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.
See Revised Paperwork Reducation Act
Statement

Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 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 21235-6401. Send only comments relating to
our time estimate to this address, not the completed form.

Form SSA-8011-F3 (07-2007)

EF (07-2007)

Page 3

SSA will insert the following revised Privacy Act Statement into the form
at its next scheduled reprinting:
Privacy Act Statement
Section 1631 (e)(1) of the Social Security Act, as amended, authorizes us to collect this
information. The information you provide will be used to enable the Social Security
Administration (SSA) to determine your potential eligibility for benefit payments and to
help us to decide if additional information is needed. Your response is voluntary.
However, failure to provide this requested information may prevent an accurate and
timely decision on any claim filed, or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for the
reasons stated above. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routines uses, which include but are not
limited to the following:
1) To enable a third party or an agency to assist Social Security in establishing rights
to Medicare benefits or coverage;
2) To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department
of Veteran’s Affairs);
3) To make determination for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4) To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Medicare programs
We may also use the information you provide in computer matching programs. Matching
programs compare our records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used
or given out are available in Systems of Record Notice 60-0089 (Claims Folders Systems,
Social Security Administration, Office of the General Counsel, Office of Public
Disclosure). There is additional information in Systems of Record Notice 60-0103
(Supplemental Security Income Record and Special Veterans Benefits, SSA, Office of
Systems, Office of Disability and Supplemental Security Income Systems). The Notices,
additional information about this form, and any other information regarding our systems
and programs, are available on-line at www.socialsecurity.gov or at your local Social
Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 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. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.