Statement of Household Expenses and Contributions

Forms and Documents

Document Name	Status
Form SSA-8011-F3 Statement of Household Expenses and Contributions - Paper Form Form and Instruction	Modified
Addendum - 0456.docx Supplementary Document	2022-01-13
Supporting Statement - 0456 (Final).docx Supporting Statement A	2022-01-13

IC Document Collections

IC ID	Document Title	Status
9338	Statement of Household Expenses and Contributions - SSI Claims System Other-SSI Claims System Screen Shot	Modified
232409	Statement of Household Expenses and Contributions - Paper Form Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0456	ICR Reference No: 202201-0960-007
Status: Received in OIRA	Previous ICR Reference No: 201807-0960-009
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Household Expenses and Contributions
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/13/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2022
Responses	419,759	425,258
Time Burden (Hours)	314,819	106,314
Cost Burden (Dollars)	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 42 USC 1382a Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 56746	10/12/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 139	01/03/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Statement of Household Expenses and Contributions - Paper Form	SSA-8011-F3	Statement of Household Expenses and Contributions
Statement of Household Expenses and Contributions - SSI Claims System

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	419,759	425,258	0	0	-5,499	0
Annual Time Burden (Hours)	314,819	106,314	0	0	208,505	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: When we last cleared this IC in 2018, the burden was 106,314 hours. However, we are currently reporting a burden of 104,940 hours. This decrease stems from an decrease in the number of responses from 425,258 to 419,759. In addition, we also separated out the paper modality from the SSI Claims System modality. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. Finally, as per OMB’s request, we included the 30-minute travel time to a field office in our burden calculations, which also increased the burden.

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Annual Cost to Federal Government: $2,219,748

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/13/2022

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