Statement of Household Expenses and Contributions - Paper Form

Statement of Household Expenses and Contributions

Documents and Forms

Document Name Document Type
Form SSA-8011-F3 Statement of Household Expenses and Contributions - Paper Form Form and Instruction
Form SSA-8011-F3 Statement of Household Expenses and Contributions - Paper Form Form and Instruction
SSA-8011-F3 Statement of Household Expenses and Contributions SSA-8011-F3 (revised).pdf Form and Instruction
SSA-8011-F3 Statement of Household Expenses and Contributions SSA-8011-F3 (revised).pdf Form and Instruction
SSA-8011-F3 (current).pdf Current SSA-8011-F3 IC Document
SSA-8011-F3 (current).pdf Current SSA-8011-F3 IC Document

Information Collection (IC) Details

IC Title:	Statement of Household Expenses and Contributions - Paper Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1130 - 416.1148

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-8011-F3	Statement of Household Expenses and Contributions	SSA-8011-F3 (revised).pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 21,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	21,000	21,000
Annual IC Time Burden (Hours)	15,750	15,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-8011-F3	SSA-8011-F3 (current).pdf	10/17/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.