Current SSA-8011-F3

Form SSA-8011-F3 (08-2017) UF
Discontinue Prior Editions
SOCIAL SECURITY ADMINISTRATION

Page 1 of 3
Form Approved
OMB No. 0960-0456

STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS
CLAIMANT'S / BENEFICIARY'S NAME

SOCIAL SECURITY NUMBER

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
TOTAL 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) named gave for the household expenses listed in Part I. Provide
your answer for the blocks we have checked.
AVERAGE MONTHLY AMOUNT GIVEN
AMOUNT GIVEN
NAME
from
through
in
$

$

$

$

$

$

Form SSA-8011-F3 (08-2017)

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PART III - OTHER ARRANGEMENTS
1.
2.
3.

Do(es)

eat every meal during the month some where else?

Do(es)

buy all his/her/their own food with his/her/their
own money?

Do(es)

pay a certain amount just for household food?

*If "Yes" how much each month?

NO

YES

NO

YES*

NO

AMOUNT

Name

$

Name

$

Name

4.

YES

$
Do(es)

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

YES*

*If "Yes" how much each month?

NO

AMOUNT

Name

$

Name

$

Name

$

PART IV-REMARKS-Use this space for any additional explanations.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
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) 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 (08-2017)

Page 3 of 3

PRIVACY ACT STATEMENT

Collection and Use of Personal Information
Sections 1612(a)(2)(A) and 1631(e)(1)(A)-(B) of the Social Security Act, as amended, allow us to collect this information. We will
use the information you provide to determine your eligibility for benefits and benefit payment amounts.
Furnishing us this information is voluntary. However, failing to provide all or part of the information could prevent us from making
an accurate decision on your claim and could result in the loss of benefits.
We rarely use the information you supply for any purpose other than what we state above. However, we may use the information
for the administration of our programs including sharing information:
1.

To comply with Federal laws requiring the release of information from our records (e.g., to the Government Accountability
Office and Department of Veterans Affairs); and,

2.

To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of our
programs (e.g., to the Bureau of the Census and to private entities under contract with us).

A list of when we may share your information with others, called routine uses, is available in our Privacy Act System of Records
Notices, 60-0089, entitled Claims Folders Systems, and 60-0103, entitled Supplemental Security Income Record and Special
Veterans Benefits. Additional information about these and other system of records notices and our programs is available from
our Internet website at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching programs compare our records with
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 incorrect
payments or delinquent debts under these programs.

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.