TN 63 (12-08)

SI 00835.625 SSA-8011 — Statement of Household Expenses and Contributions

A. Policy for use of the SSA-8011

1. When to use Form SSA-8011

Use the SSA-8011-F3 to verify the following items as required by
SI 00835.140 - SI 00835.200 and SI 00835.340:

  • household operating expenses;

  • the individual's contribution to household operating expenses;

  • separate consumption;

  • separate purchase of food; or

  • earmarked contributions.

NOTE: Use the SSA-8011-F3 when it is not feasible to document the file solely on MSSICS.

2. Exception—when an SSA-8011 is not required

If the representative payee has completed Part II of the SSA-8006-F4 on the individual's behalf and is the householder, an SSA-8011-F3 is not necessary.

3. Who provides information on the SSA-8011

The householder or knowledgeable adult member of the individual's household (other than the individual's spouse) provides the information.

B. Procedure for interviewing the householder/knowledgeable adult respondent

1. Respondent is at the interview or on the telephone

If the respondent is at the interview or on the telephone:

  • Review with the respondent the information provided by the claimant, located on the LOHH screen;

  • If the information received from the respondent is not consistent with the claimant’s statements, update the LOHH screen accordingly and document on a DROC Screen, (e.g., “Contacted householder Frank Johnson, information was not consistent, updated LOHH screen.”); or

  • If the claimant’s and respondent’s statements are consistent, document on a DROC screen, (e.g., “Contacted householder Frank Johnson, information consistent with LOHH screen.").

2. Respondent is not at the interview and not available by telephone:

If the respondent is not at the interview and not available by telephone, use the SSA-8011-F3:

  • Mark the SSA-8011 to indicate which questions to answer, about whom the information is requested, and the living arrangement period for which information is being requested;

  • Ask the claimant/recipient to have the respondent complete the remainder of the form and sign it; and

  • Tell the claimant/recipient that he or she is responsible for the return of the form to the field office. Use the SSA-L8009-U3 (SI 00601.120) in initial claim situations and the SSA-L8003-U2 (SI 02306.020) for PE situations. Provide a postage-paid return envelope for the respondent to use.

3. Electronic documentation requirements for the paper SSA-8011

If a paper SSA-8011-F3 is received from the respondent:

  • For MSSICS cases, document the information on the DROC screen as in SI 00835.625B.1. in this section, and update the LOHH screen(s) accordingly;

  • If the SSA-8011 information cannot be documented on DROC (e.g., not a MSSICS claim), fax the SSA-8011 into the appropriate electronic folder;

  • Do not retain the paper form after the issue has been documented electronically.

For more information on storing forms electronically refer to GN 00301.322 “Retention of Paper Material After Faxing into Either the eDIB folder or Claims Folder using NDRed”.

C. Procedure for completing Form SSA-8011

1. Identification lines


NOTE: Due to privacy concerns, do not include claimant’s entire SSN when completing the SSA-8011-F3.

2. Part I — Household expenses

Check the block to indicate Part I should be completed.

a. Averaging period

In the spaces provided, indicate the period for which the fluctuating expenses must be averaged. (For rules on the averaging period, refer to SI 00835.475.)

NOTE: If it is necessary to document more than one averaging period for expenses, use additional SSA-8011-F3’s as supplements.

b. Month for non-fluctuating expenses

In the space provided