TN 63 (12-08)
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 purchase of food; or
NOTE: Use the SSA-8011-F3 when it is not feasible to document the file solely on MSSICS.
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.
The householder or knowledgeable adult member of the individual's household (other
than the individual's spouse) provides the information.
If the respondent is at the interview or on the telephone:
Review with the respondent the information provided by the claimant, located on the
Household of Another page;
If the information received from the respondent is not consistent with the claimant’s statements, update the Household of Another page accordingly
and document on a DROC Screen, (e.g., “Contacted householder Frank Johnson, information
was not consistent, updated the Household of Another page.”); 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 the Household of Another page.").
If the respondent is not at the interview and not available by telephone, use the
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
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 Household of Another page(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
NOTE: Due to privacy concerns, do not include claimant’s entire SSN when completing the
Check the block to indicate Part I should be completed.
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.
In the space provided, indicate the month for which a determination is being made.
Line through “Food” if the claimant/recipient alleges separate consumption /purchase
If appropriate, check the block to indicate Part II should be completed.
Enter the name(s) of the individual(s) alleged to be contributing (claimant/ recipient
Check the appropriate block(s) to request the average of contributions and/or an amount
paid in a particular month. Use both blocks when a significant change in contributions must be documented as well as average contributions for another month's determination. (This should rarely be necessary.)
Enter the months for which the average contribution is solicited. For rules on averaging
contributions, see SI 00835.480.
NOTE: If it is necessary to document more than one averaging period for contributions, use
additional SSA-8011-F3 forms as supplements.
In the “Amount given in” block, enter the month in which there is a significant change
in the individual's contribution that did not continue. For example, enter the month
a prepayment is alleged.
If appropriate, check the block(s) in Part III that describes the alleged arrangement
for food and shelter and enter the name(s) of the person(s) who has the arrangement
(claimant/recipient or deemors).
To view this form, go to SSA-8011–F3.