Identification Number:
SI 00835 TN 86
Intended Audience:See Transmittal Sheet
Originating Office:ORDP OISP
Title:Living Arrangements and In-Kind Support and Maintenance
Type:POMS Transmittals
Program:Title II (RSI),Title XVI (SSI)
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part SI – Supplemental Security Income
Chapter 008 – Income
Subchapter 35 – Living Arrangements and In-Kind Support and Maintenance
Transmittal No. 86, 07/01/2019

Audience

FO/TSC: CS, CS TXVI, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

OISP

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.

Summary of Changes

SI 00835.510 Breakpoints

Changed "MSSICS" to "SSI Claims System" throughout this document to reflect the new claim system, per modernization updates. The term “Non-MSSICS” has not changed.

 

SI 00835.600 SSA-8006-F4 — Statement of Living Arrangements, In-Kind Support and Maintenance

Changed "MSSICS" to "SSI Claims System" throughout this document to reflect the new claim system, per modernization updates. The term “Non-MSSICS” has not changed.

 

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

Changed "MSSICS" to "SSI Claims System" throughout this document to reflect the new claim system, per modernization updates. The term “Non-MSSICS” has not changed.

SI 00835.510 Breakpoints

A. Definition of breakpoints

A breakpoint is an event which signals a possible change in the value of inside or outside in-kind support and maintenance (ISM). It may signal a change in the way inside ISM is valued: value of the one-third reduction (VTR) vs. presumed maximum value (PMV) or it may mean that ISM has started or stopped. Further investigation is necessary to determine if the event actually affects the living arrangement (LA) or ISM.

B. Policy related to ISM breakpoints

1. Inside ISM breakpoints

The following are inside ISM breakpoints. A change in:

  • ownership interest or rental liability;

  • public assistance (PA) household status;

  • separate purchase or consumption;

  • contribution to household expenses (For significant changes in contribution which include the beginning or end of a loan of ISM see SI 00835.480D.2.);

  • household composition;

  • non-fluctuating household operating expense;

  • earmarking; and

  • residence.

2. Outside ISM breakpoints

The following events are outside ISM breakpoints. A change in:

  • household composition;

  • household payment towards the household cost;

  • the current market value (CMV) of the household cost — due to a change in the vendor charge or if there is no vendor charge, a change in the estimate of the CMV which results from an identifiable event (For additional instructions on LA and ISM see SI 00835.515 through SI 00835.520);

  • provision of household cost - the starting or stopping of someone outside the household providing household costs; and

    NOTE: The beginning or end of a loan of outside ISM is a change in the provision of household cost. For more information on developing loans of ISM see SI 00835.482.

  • residence.

3. Explanation of a change in residence

Always evaluate and develop the LA basis and ISM in a new residence. A change in residence differs from other breakpoints in that it is not the change itself which causes a change in ISM. A change in residence usually means one or more of the other factors which affect the computation of inside or outside ISM has changed. For example, a change in residence usually means the average household operating expenses have changed. It often means a change in household composition as well.

REMINDER: A change of residence occurs when an individual's temporary absence due to medical confinement or school attendance ceases for a reason other than return to the permanent living arrangement. For information on temporary absence see SI 00835.040 through SI 00835.043.

4. Effective month of breakpoints

The following chart shows the effective month of change for all breakpoints. The effective months are based on principles relating to the LA basis and contributions to household expenses. For information about the LA basis, see SI 00835.001.

EVENTS

EFFECTIVE
MONTH OF
CHANGE

Change in ownership interest or rental liability (from VTR)

Month it occurs

Loss of ownership interest or rental liability

Month after it occurs

PA household:

 

Member starts receiving PA

Month it occurs

Member stops receiving PA

Month after it occurs

Member without PA moves in or out

Month after it occurs

Change to separate purchase/
consumption

First full month it occurs

Change from separate purchase or consumption

Month it occurs

Change in contribution to household expenses

Month it occurs

Change in household composition

Month after it occurs

Change in non-fluctuating household operating expense

Month it occurs

Change to earmarking

First full month it occurs

Change from earmarking

Month it occurs

Change in household payment toward the household cost

Month it occurs

Change in CMV of household cost

Month it occurs

Change in provision of household costs by someone outside the household

Month it occurs

Residence change (For information on applying the First of the Month Rule (FOM) see SI 00835.500)

Month after it occurs

References:

SI 00835.110, Home Ownership as LA Basis

SI 00835.170, Earmark Sharing

SI 00835.480, Contribution Toward Household Operating Expenses

SI 00835.482, Loans of In-Kind Support and Maintenance

SI 00835.485, Household Composition

SI 00835.500, First-of-the-Month (FOM) Residence and ISM Determinations

SI 00835.350, Computation of In-Kind Support and Maintenance from Outside a household (Including Vendor Payments by a Third Party Outside the Household)

SI 00835.380, Rental Subsidies

C. Policy for evaluating breakpoints

When a breakpoint is reported, determine if it affects the LA basis, inside ISM or outside ISM. Follow these guidelines:

1. Inside ISM breakpoints

a. Gain or loss of ownership interest or rental liability

This may mean a change from or to the VTR or require the investigation of cash contributions from others in the household, therefore, always fully evaluate these situations.

b. Gain or loss of PA household status

Consider the following when a PA household status change occurs:

  • If PA household status is gained, no ISM development needs to be done because of the presumption of sharing.

  • If PA household status is lost, full LA and ISM development must be done.

c. Starting or stopping separate purchase or separate consumption

This always requires an evaluation of the ISM in the new situation.

d. Change in contribution to household expenses

When a change in contribution occurs:

  • Presume there has been no change in ISM if the individual's contribution decreases and the individual is being charged some inside ISM; and

  • Reevaluate the ISM if the contribution significantly changes. For discussion of significant changes in contribution including the beginning or end of a loan of ISM see SI 00835.480D.2.

e. Change in household composition

A change in household composition is significant because both the relationship of the persons with whom the individual shares the household and the number of household members are material to the determination of ISM.

The relationship of the persons with whom the individual shares the household is significant since inside ISM is only an issue when the individual lives with someone other than a spouse, children, or someone whose income may be deemed to the individual. For an exception to this rule see SI 00835.340.

EXAMPLE:  The individual lives with her child and another adult who is not the individual's spouse or deemor. ISM must be developed. When the other adult moves out of the household, inside ISM is no longer an issue.

A change in the number of persons in the household is significant because it may result in an increase or decrease in the household operating expenses. This change does not necessarily change the pro rata share of household operating expenses because those expenses, especially for food, may change proportionately. However, in order to determine the effect that the change in the number of persons living in the household has upon inside ISM, always develop the issue when the number of persons in the household changes and inside ISM remains an issue that must be developed.

f. Change in non-fluctuating household operating expense

Presume no change in ISM occurred if a non-fluctuating expense:

  • increases and the individual is already charged with the VTR or PMV; or

  • decreases and there is no ISM identified as inside ISM on the Supplemental Security Record (SSR).

For an explanation of non-fluctuating expenses see SI 00835.475C.

g. Change in earmarking

Consider the following when a change in earmarked contributions occurs. If earmarking:

  • begins, ISM must be reevaluated; or

  • stops, the VTR is charged unless there are other changes involved.

h. Change in residence

Always reevaluate the ISM.

2. Outside ISM breakpoints

a. Change in household composition

No material change occurs if the household composition decreases and the individual is being charged the PMV.

b. Change in household payment towards the household cost

No material change occurs if the household payment decreases and the individual is already being charged the PMV.

c. Change in CMV of the household cost

No material change occurs if the CMV increases and the individual is already being charged the PMV.

d. Change in provision of household cost by someone outside the household

The beginning or stopping of provision of household cost by someone outside the household always requires further development. The beginning or end of a loan of ISM from outside the household is an example of a change in provision of household cost. For more information on developing and computing loans of ISM outside the household see SI 00835.482.

e. Change in residence

Evaluate the effect of a change in residence on items SI 00835.510C.2.a. through SI 00835.510C.2.d.

D. Procedure for documenting breakpoints

Breakpoints are usually discovered as part of a redetermination or as a timely report unconnected with a redetermination. If the breakpoint has no effect on ISM no documentation is required. For information on evaluating breakpoints see SI 00835.510C (in this section).

EXCEPTION: If the last living arrangement was based on a continuing loan of ISM, the living arrangement and ISM must be fully developed and documented regardless of the effect on ISM.

1. Inside ISM

a. Breakpoint is material

If the breakpoint is material, document a description of the change and the date the change occurred:

  • on a DROC screen within the SSI Claims System; or

  • on a paper SSA-5002 for non-MSSICS cases.

Document the file by faxing the SSA-5002 form directly into the appropriate electronic folder. Do not retain the paper SSA-5002 after you document the issue electronically.

b. Date of change unknown or uncertain

If the individual does not know or is unsure about the month and year, contact a knowledgeable party and record his or her response:

  • within the SSI Claims System on a DROC screen; or

  • on a paper SSA-5002 for non-MSSICS cases.

  • Document the file by faxing the SSA-5002 form directly into the appropriate electronic folder. Do not retain the paper SSA-5002 after you document the issue electronically.

c. Breakpoint affects LA basis or inside ISM

If the breakpoint could affect the LA basis or inside ISM determination:

  • Complete the SSI Claims System living arrangement pages to document the situation as of the breakpoint effective month; or

  • For non-MSSICS cases it may be necessary to complete Part I and Part II of the SSA-8006 (Statement of Living Arrangements, In-Kind Support and Maintenance) in order to document the situation as of the effective month of the breakpoint. For information on completing the household expense portion of the SSA-8006 see SI 00835.475 and SI 00835.600.

d. Documentation and computation of ISM

For documenting the living arrangement and computing the ISM follow the requirements in SI 00835.110 through SI 00835.170, SI 00835.320, and SI 00835.340.

2. Outside ISM

a. Breakpoint affects ISM

If the breakpoint affects ISM:

  • document it on DROC screen within the SSI Claims System with a description of the change and the CMV of the item received and the month(s) it was received; or

  • on a paper SSA-5002 for non-MSSICS cases with a description of the change and the CMV of the item received and the month(s) it was received. Document the file by faxing the SSA-5002 form directly into the appropriate electronic folder. Do not retain the paper SSA-5002 after you document the issue electronically.

b. Date of change unknown or uncertain

If the individual does not know the month(s) the outside ISM was received, contact a knowledgeable party and record his or her response:

  • on a DROC screen within the SSI Claims System; or

  • on a SSA-5002 for non-MSSICS cases.

Document the file by faxing the SSA-5002 form directly into the appropriate electronic folder. Do not retain the paper SSA-5002 after you document the issue electronically.

c. Documentation and computation of ISM

For documenting and computing the new value of ISM follow the requirements in SI 00835.350.

SI 00835.600 SSA-8006-F4 — Statement of Living Arrangements, In-Kind Support and Maintenance

A. Introduction

The SSA-8006-F4 is an interviewing and development tool for living arrangement (LA) and in-kind support and maintenance (ISM). The answers to the questions on the SSA-8006-F4 document the individual's allegations regarding:

B. When to use Form SSA-8006-F4

Only use the SSA-8006-F4 when the SSI Claims System is not used to develop LA/ISM.

Sometimes the SSA-8006-F4 is used as an extension of a paper application, redetermination, or application update form, but it may also stand on its own (e.g., in posteligibility situations). You may need more than one to document changes in LA/ISM over time.

The following are guidelines for using the form:

  • An SSA-8006-F4 must reflect LA/ISM information pertinent to a single residence.

  • When there is more than one residence to document on a case, make it clear to which residence each SSA-8006-F4 refers.

  • If you need more than one LA/ISM determination due to breakpoints during the period of review (see SI 00835.510), document these changes on separate SSA-8006-F4s. The period represented by each SSA-8006-F4 and the effective dates of each LA/ISM determination must be clear from the file.

C. When to use Part I of the SSA-8006-F4

Use Part I in limited initial claim and posteligibility (PE) situations. The questions in this part cover the basic circumstances in the individual’s residence (e.g., whether the individual lives alone or with others). These questions also cover the LA bases through public assistance (PA) household in the sequence of LA development (i.e., institution, noninstitutional care, home ownership, rental liability, and PA household). (See Policy – Sequence of Development for LA Basis SI 00835.001B.)

Complete P art I:

  • When a change in residence or LA basis occurs during or subsequent to the month of filing, the claim is still pending in the FO, and an SSA-8203-BK has not been used to develop the change.

  • When inside ISM is being developed in connection with the Data Operations Center (DOC) exclusion involving ISM at less than the presumed maximum value (PMV) posted to the Supplemental Security Income Record (SSR).

  • Whenever an individual reports a breakpoint and you must have information to determine the change in LA or ISM, if any (see SI 00835.510 “Breakpoints”).

D. When to use Part II of the SSA-8006-F4

Use Part II to determine if an individual receives ISM from inside the household, e.g., cases involving the value of the one-third reduction (VTR) or presumed maximum value (PMV). Part II is designed to cover all points necessary to establish an LA basis lower in the sequence of living arrangement development than a PA household (i.e., separate consumption, separate purchase of food, sharing, earmarked sharing, and the VTR) and to obtain the individual's allegation of the amount of ISM received from within the household, if any.

Complete P art II:

In addition to the application, redetermination, application update forms, or Part I of the SSA-8006-F4, when the individual lives with someone other than a spouse, child, or someone whose income is deemable to the individual unless:

  • the individual resides in a PA household;

  • the individual is a child under age 18 living only with a parent (and children, if present); or

  • the individual is the householder and the others in the household do not contribute to the household operating expenses.

If the individual lives only with children who have income and there is a question of unstated income or, in the claims representative's judgment, there is a probability of inside ISM, complete Part II unless one of the exceptions above applies. (See SI 00835.340 “Computation of ISM from Within a Household”.)

When a breakpoint is reported, use Part II to determine any change in LA or ISM.

E. When to use Part III of the SSA-8006-F4

This part refers to the individual's responsibility to notify SSA of any changes that could affect his or her benefit amount.

It authorizes sources to release information to SSA needed to verify allegations, and it informs the individual, through a penalty clause, that failure to report any changes could result in a penalty. There is also space for the signature of the individual and space for witnesses, should their signatures be required. Part III must be completed whenever the SSA-8006-F4 is completed in whole or in part.

F. Procedure for completing the SSA-8006-F4

The SSA-8006-F4 is not a self-help form. It is designed to be completed only with interviewer assistance (either by telephone or face-to-face).

1. General

Be sure the individual understands the questions being asked, why the questions are being asked, and the penalties for failing to report or for giving false information. Do not record any third-party verification on this form. Obtain this information separately (except when a representative payee, who is completing the form on behalf of the claimant/recipient, is also the householder).

Whenever a question on the form is inappropriate or otherwise documented in file and thus is unanswered, line through the question or annotate the question in some other manner to indicate that it is not needed.

NOTE: When the instructions say “spouse,” it means only a “living-with spouse.” Similarly, for a child, “parent,” means “living-with parent.”

2. Identifying information

Enter the name(s) of the eligible individual or couple for whom the form is being completed.

If the eligible individual and eligible spouse are separated, use a separate form for each person, beginning with the month after the month they separated.

3. Date of change of living situation (if applicable)

Enter the date (month/day/year) when the change in the eligible individual's or couple's living situation occurred that makes this SSA-8006-F4 necessary.

NOTE: A date entry is not necessary when you use the form in conjunction with a redetermination and no change has occurred (see SI 00835.520 “Redetermination Guidelines – LA and ISM”).

4. Type of change (e.g., residence, household composition, contribution amount)

Enter the type of change that has occurred.

For a complete list of the changes (breakpoints) that affect in-kind support and maintenance, see SI 00835.510 “Breakpoints”.

5. Period covered by the SSA-8006-F4

Enter the months for which the information on the SSA-8006-F4 applies.

6. Part I, Question 1.

Check the blocks that best describe your living arrangements .

Q uestion 1.A.: I live (with):

Complete this statement whenever you use Part I. Check all the applicable blocks. Complete this statement from the perspective of the claimant/recipient.

a. Alone

Check this block when an individual lives alone in a household of one, is in an institution, or is a transient.

Households of one include noninstitutional care situations (SI 00835.790) and may include room rentals in private or commercial establishments (SI 00835.120 “Rental Liability as LA Basis”). (For the definition of household, see SI 00835.020).

When this block is checked, do not check any other block in Question 1.A.

b. Eligible spouse

Check this block when an eligible individual lives with his or her eligible spouse. (This includes a spouse who is applying for SSI).

If “Child(ren)” as well as “Eligible Spouse” is checked, see c. below. If “Other People” as well as “Eligible Spouse” is checked, see d. below.

c. Ineligible spouse, parent, children, essential person, or sponsor

Check “Child(ren)” when an individual lives with a child(ren) as defined in SI 00501.010. Check “Ineligible Spouse”, “Parent(s)”, “Essential Person”, or “Sponsor”, as appropriate, when the eligible individual lives with a person(s) from whom income may be deemed.

If a parent or ineligible spouse is also an individual's sponsor, check “Parent” or “Ineligible Spouse”.

If a parent or ineligible spouse is also the individual's essential person, check “Essential Person”.

d. Other people

Check this block when an individual lives with a person who is not an eligible spouse, a child as defined in SI 00501.010 or an adult from whom income may be deemed.

If the individual is a child under age 18, check this block if he or she lives with at least one adult other than parent(s). Also, if the individual is a child under age 18, check this block when the child lives only with a parent(s) from whom income cannot be deemed.

Question 1.B.: I live in a:

Complete this question whenever Part I is used. Check only the applicable block.

If “Room (private home)” is checked, develop the issue of separate households per SI 00835.120D “Rental Liability as LA Basis”.

If “Mobile Home” is checked, see SI 00835.465 “ISM and Households – Household Costs” for instructions for determining items of shelter.

Check “Other” when an individual lives in a place other than those listed on the SSA-8006-F4. When an individual is in an institution, noninstitutional care, or is a transient, curtail completion of the SSA-8006-F4 because the remaining questions concern persons living in households. Line through the balance of questions contained in Parts I and II, and have the individual complete Part III.

Question 1.C.: Total number of people in household (including yourself)

Answer this question whenever you use Part I unless the individual is a transient, living in an institution, or living in a noninstitutional care situation.

This space should reflect the total number of permanent household members, including the individual (couple).

See Details:

For the definition of household, see SI 00835.020.

For a discussion of separate households, see SI 00835.120.

For the effective date of a change of composition in a household, see SI 00835.510.

7. Part I, Question 2.

Check “Yes” or “No” to the following questions and provide additional information as requested.

Question 2.A.: Do you (and/or your spouse or deemor) own or are you (and/or your spouse or deemor) buying the home you live in?

Answer this question whenever Part I is used unless the individual is a transient, living in an institution, or living in a noninstitutional care situation.

Question 2.B.: Do you (and/or your spouse or deemor) rent the place where you live?

If Question 2.A. is answered “NO,” answer Question 2.B.

“The place” in Question 2.B. refers to the individual's residence (for the definition of residence, see SI 00835.020).

Question 2.C.: Does anyone who lives with you rent the place where you live?

If Question 2.B. is answered “NO,” answer Question 2.C.

This question determines if any other household member has rental liability.

If answered “YES,” rental subsidy (SI 00835.380) may be involved if any household member is related to the landlord (landlord's spouse) as a parent or child.

If this question is answered “NO,” and no household member owns the dwelling, then either ISM in the form of rent-free shelter (SI 00835.370) or remuneration for services exists (SI 00835.390), and further development is required to determine which applies.

Where services are alleged as part or all of the required rent, always resolve whether the shelter is earned or unearned remuneration prior to considering rental subsidy or rent-free shelter (see Food or Shelter that is Remuneration for Work but is not Wages SI 00835.390).

Question 2.D.: Are you or anyone you live with related to the landlord (landlord's spouse)?

If either Questions 2.B. or 2.C. are answered “YES,” answer Question 2.D.

If this question is answered “YES,” write the relationship that exists with the landlord (landlord's spouse) and consider the possibility of rental subsidy in accordance with SI 00835.380 “Rental Subsidies”.

Question 2.E.: If you answered “YES” to B. or C., provide the following information.

If either Question 2.B. or 2.C. is answered “YES,” write the landlord's name, address, telephone number, and the date the rental agreement began in the space provided. (The monthly rental amount should be the required rent). See SI 00835.380B “Rental Subsidies”.

8. Part I, Question 3.

Question 3.: Does any agency, organization, or anyone who does not live with you pay for, or help you pay for, any of the following items: food, rent, home mortgage payments, property insurance (if required by mortgage holder), real property taxes, heating fuel, gas, electricity, garbage removal, water, or sewer bills?

Answer this question whenever you complete Part I unless the individual is a transient, living in an institution, or living in a noninstitutional care situation.

NOTE: A “YES” response can mean that the individual is receiving chargeable ISM or cash from outside the household.

Complete the boxed-in area for information about each item and follow SI 00835.350 through SI 00835.450 for development and documentation. However, consider whether such cash or ISM may be excluded in accordance with SI 00835.001 “Introduction to Living Arrangements and In-Kind Support and Maintenance” and SI 00830.000 ”Unearned Income”.

9. Part I, Question 4

Question 4: If you live with others, do all other household members receive some type of public payment based on need (e.g., TANF , BIAGA, SSI, VA)?

Answer this question any time the individual/couple lives with anyone other than a spouse or person whose income may be deemed.

By answering “YES”, the individual alleges a PA household (SI 00835.130). When there is a PA household, there is no inside ISM chargeable subject to the VTR or PMV.

If this question is answered “YES,” provide the name of the agency and proceed to Part III. If this question is answered “NO” proceed to Part II.

10. Part II, Questions 1.A. and 1.B.

Questions 1.A. and 1.B.: Do you eat your meals out ? Do you buy all of your food separately from other household members?

These questions apply to all individuals.

“No” answers to both questions mean that the individual eats meals with other household members and does not purchase the food separately. A “Yes” response to either question indicates that there is separate consumption/purchase of food and that the VTR does not apply. Any ISM received from within the household is shelter and subject to the PMV rule.

For development and documentation instructions, see SI 00835.140 “Separate Consumption” and SI 00835.150 “Separate Purchase of Food”.

If the individual is a child under age 18 and a living-with parent purchases food on behalf of the child, answer “yes” to Question 1.B. Explain the separate purchase situation in “Remarks” or next to the question.

For eligible couples, ask these questions of each member of the couple. If either member answers “yes” to either question, explain in “Remarks” or next to the question.

11. Part II, Question 1.C.

Question 1.C.: How much is your average cash contribution per month toward the household expenses listed below?

This question applies to all individuals.

Enter the amount the individual contributes from his or her own funds.

In addition, if the individual lives with a deemor, show the amount contributed by the deemor in “Remarks,” or elsewhere in the file. If applicable, include information necessary to determine how much, if any, of the ineligible person's contribution may be allocated to the eligible individual per SI 00835.210 “The One-Third Reduction Provision and Deeming”.

For example, you may need to show the number of ineligible children to whom an excess contribution must be allocated.

For eligible couples, enter the amount of their combined contribution.

If the individual alleges no contributions toward household operating expenses, enter “0” or “none”.

For information on how to compute the average contribution, see SI 00835.480 “Contributions Toward Household Operating Expenses”.

12. Part II, Question 1.D.

Question 1.D.: Do you have an agreement to pay back the people you live with for your share of the household expenses?

This question applies to individuals who receive food and/or shelter from a member of the household and whose average cash contribution does not meet the pro rata share of the household expenses.

If this question is answered “YES,” see instructions for developing loans of food and/or shelter in SI 00835.480.

13. Part II, Question 2.

Question 2.: If you or your spouse own or rent, show the total monthly cash contributions from others with whom you live.

Get an answer for this question whenever the individual or his or her spouse has ownership interest or rental liability for the place where he, she, or they reside and there is at least one household member who is not a child, spouse, or person whose income may be deemed to the individual.

The answer indicates whether the individual receives cash income from within the household.

Enter the total amount the other household members contribute. (See SI 00835.340 “Computation of In-Kind Support and Maintenance from Within a Household”.)

To determine the amount of cash income received, use the worksheet in SI 00835.450B.2.

If other household members do not contribute, enter “none” or “0”.

14. Part II, Questions 3.A. and 3.B.

Questions 3.A. and 3.B.: Is part or all of the amount in question 1.C. just for food ? Is part or all of the amount in question 1.C. just for shelter?

These questions identify contributions earmarked for food only, for shelter only, or partly for each. (For development and documentation, see SI 00835.170 “Earmarked Sharing”).

The only individuals who must answer these questions are those who

  • have neither ownership interest nor rental liability;

  • do not eat all meals out; and

  • do not purchase food separately.

If the individual lives with a deemor, check “yes” only if the individual's own or the deemor's contribution is earmarked. Indicate the amounts contributed by the individual and deemor and refer to SI 00835.210 “The One-Third Reduction Provision and Deeming” to determine the total contribution attributed to the individual.

15. Part II, Question 4.

Question 4: What is the average monthly amount of the following household cash expenses for the periods indicated?

Question 4. covers the household's average monthly cash expenditures for food and the shelter items listed in SI 00835.465 “ISM and Households – Household Costs”.

If the household does not have one or more of these expenses, enter “none” or “0” in the appropriate block.

Use the “From-Through” block to designate the period over which the household expenses are averaged. The averaging period is usually the 12 months prior to the month the LA/ISM determination is needed. (You may use the additional columns to document a breakpoint involving a change in a non-fluctuating expense.)

If the individual cannot estimate one or more of the expenses, annotate the items with “cannot estimate” or words to that effect.

For more information on converting and averaging expenses, see SI 00835.470 through SI 00835.475.

NOTE: You need the average monthly food expense only when questions 1.A. and 1.B. are both answered “no”. A “yes” answer to either of these questions means that the individual alleges not sharing in the household's food. Therefore, any ISM the individual receives from other household members takes the form of shelter.

There are four situations where answering Question 4 is not necessary:

  • If no LA basis higher in the sequence than sharing has been established and the individual contributes nothing to household expenses, the VTR applies.

  • If no LA basis higher in the sequence than sharing is alleged and the individual makes a “token” contribution, the VTR applies. (See SI 00835.160 “Sharing”)

  • If the individual, who is not the householder, is unable or unwilling to provide answers regarding the household expenses, request evidence.

  • If the individual alleges a loan that covers the pro rata share of household expenses and the developmental tolerance in SI 00835.480F.2.a. applies.

16. Part II (Remarks)

Use this section to record information explaining or clarifying any of the answers to questions in Parts I or II.

17. Part III (Your Responsibilities)

Complete Part III whenever the SSA-8006-F4 is completed in whole or in part.

G. Procedure for documenting the paper SSA-8006-F4

Use the following documentation procedure only when you are unable to input the information directly in the SSI Claims System.

  • If you use a paper SSA-8006-F4 to develop living arrangements and the claimant does not have an active SSI Claims System case, document the file by faxing the SSA-8006-F4 form directly into the appropriate electronic folder.

  • If you use the paper SSA-8006-F4 because the SSI Claims System is temporarily unavailable, retain the SSA-8006-F4 until you can input the information into the SSI Claims System.

  • If you complete an SSA-8006-F4 over the telephone with the claimant, annotate the remarks section with the name of the claims representative, field office number, determination, and state, “SSA-8006-F4 was completed over the telephone with the claimant. The claimant’s signature is not required.”

  • Do not retain the paper SSA-8006-F4 after you document the issue 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”.

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 through 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 in the SSI Claims System.

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 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.").

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 SSI Claims System 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 SSI Claims System 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

Self-explanatory.

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, indicate the month for which a determination is being made.

c. Food item

Line through “Food” if the claimant/recipient alleges separate consumption /purchase of food.

3. Part II — Contributions

If appropriate, check the block to indicate Part II should be completed.

a. Contributors' names

Enter the name(s) of the individual(s) alleged to be contributing (claimant/ recipient or deemors).

b. Checking the blocks

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.)

c. Averaging period

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.

d. Month of significant change

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.

4. Part III — Other arrangements

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).

5. Part IV — Remarks

Self-explanatory.

D. Exhibit — Form SSA-8011-F3

To view this form, go to SSA-8011–F3 .


SI 00835 TN 86 - Living Arrangements and In-Kind Support and Maintenance - 7/01/2019