Statement of Household Expenses and Contributions - SSI Claims System

The attached SSI claim system pages are used to collect information from the SSI claimant or
recipient about in-kind support and maintenance. Form SSA-8011-F3 is used to verify with the
householder the information on these SSI claims system pages, which the claimant or recipient
has provided. Form SSA-8011-F3 is not a replication of the collection on these SSI claims
system pages. Form SSA-8011-F3 collects only the information that is needed from the
householder to verify the claimant’s or recipient’s in-kind support and maintenance.
FACSIMILE 1: HOUSEHOLD OF ANOTHER – CLAIM IS FOR AN INDIVIDUAL
[1-D]
PERIOD EFFECTIVE DATES SS/SS/SSSS – SS/SS/SSSS
HOUSEHOLD OF ANOTHER
*INDICATES REQUIRED INFORMATION
[2-M]
*EATS ALL MEALS OUT
( ) YES ( ) NO ( ) UNKNOWN
[3-C]
*BUYS FOOD SEPARATE FROM HOUSEHOLD
( ) YES ( ) NO ( ) UNKNOWN
[4-C]
*WISH TO REBUT PRESRUMED MAXIMUM VALUE (PMV)
( ) YES ( ) NO ( ) UNKNOWN
[5-C]
*CLAIMANT OR DEEMOR CONTRIBUTES TOWARD HOUSEHOLD EXPENSES
( ) YES ( ) NO ( ) UNKNOWN
[6-C]
*CLAIMANT MAKES TOKEN CONTRIBUTION
( ) YES ( ) NO ( ) UNKNOWN
[7-C]
*DEEMOR MAKES TOKEN CONTRIBUTION
( ) YES ( ) NO ( ) UNKNOWN
CONTRIBUTION AVERAGE PERIOD
[8-C]
[9-C]
*DATE FROM PP/PPPP [] UNKNOWN
(MM/YYYY)

*DATE TO PP/PPPP [] UNKNOWN
(MM/YYYY)

[10-C]
*CLAIMANT’S CONTRIBUTION $9999.99 [ ] UNKNOWN
[11-C]
*MONTHLY LOAN AMOUNT $9999.99 [ ] UNKNOWN

EXPENSE AVERAGE PERIOD
[12-C]
[13-C]
*DATE FROM PP/PPPP [ ] UNKNOWN
(MM/YYYY)

*DATE TO PP/PPPP [ ] UNKNOWN
(MM/YYYY)

*MONTHLY EXPENSES
FOR THE PERIOD ABOVE, COLLECT THE FOLLOWING EXPENSES
[14-C]
[15-P]
[16-C]
[17-C]
[18-C]
[19-C]
[20-C]
[21-C]
[22-C]
[23-C]
*FOOD($) *MORTGAGE *PROPERTY
*PROPERTY *HEATING *ELECTRICITY($) *GAS($) *GARBAGE
*SEWER($) UNKNOWN
OR RENT($) INSURANCE($) TAXES($) FUEL($)
REMOVAL($)
9999.99 PPPP.PP
9999.99
9999.99 9999.99 9999.99
9999.99 9999.99
9999.99 9999.99

[24-C]
*WATER($)

[25-D]
TOTAL MONTHLY EXPENSES $SSSSS.SS
[26-D]
PRO RATA SHARE FOR (CLAIMANT FIRST NAME + LAST NAME) – (SSN) – (RELATIONSHIP) $SSSS.SS
DEEMOR CONTRIBUTION
[27-D]
DEEMOR

[28-C]
*DEEMOR
CONTRIBUTION
AMOUNT($)
9999.99

[29-D]
[30-D]
DEEMOR
CLAIMANT’S
EXCESS
SHARE OF
CONTRIBUTION($) EXCESS($)
SSSS.SS
SSSS.SS

[31-C]
[24-C]
*EARMARKED UNKNOWN
FOR
--

[]

(FIRST NAME + LAST NAME) – (SSN) – (RELATIONSHIP)
[32-D]
TOTAL CONTRIBUTION FOR CLAIMANT $SSSS.SS
[33-C]
*CONTRIBUTION AND EXPENSE VERIFICATION RECEIVED
( ) YES ( ) NO
[34-O]
CONTACT PERSON XX [MAXIMUM OF 40 CHARACTERS]XX
[35-O]
PHONE (999)999-9999
[36-C]
*CLAIMANT’S CONTRIBUTION EARMARKED FOR –
[37-C]
*FOOD AMOUNT $9999.99 [ ] UNKNOWN
[38-C]
*SHELTER AMOUNT $9999.99 [ ] UNKNOWN
[39-D]
PRO RATA FOOD SHARE FOR (CLAIMANT FIRST NAME + LAST NAME) – (SSN) – (RELATIONSHIP) $SSSS.SS
[40-D]
PRO RATA SHELTER SHARE FOR (CLAIMANT FIRST NAME + LAST NAME) – (SSN) – (RELATIONSHIP) $SSSS.SS

[41-D]
TOTAL ISM FROM HOUSEHOLD FOR (CLAIMANT FIRST NAME + LAST NAME) – (SSN) – (RELATIONSHIP) $SSSS.SS
[42-C]
*EARMARKED CONTRIBUTION VERIFIED
( ) YES ( ) NO
[43-O]
[+/-] SHOW/HIDE PERSON REMARKS
[44-O]
PERSON REMARKS (PRINTED)
XX[MAXIMUM OF 1000 CHARACTERS]XX
[45-O]
[+/-] SHOW/HIDE FILE DOCUMENTATION NOTES
[46-O]
FILE DOCUMENTATION NOTES
XX[MAXIMUM OF 1000 CHARACTERS]XX
[47-O]
[CLEAR PAGE/UNDO CHANGES]