Effective Dates: 10/01/2024 - Present Previous | Next

TN 125 (10-24)

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

NOTE: 

For living arrangement (LA) periods effective 09/30/2024 or later, use form SSA-8012 to document a claimant or recipient’s statement about household expenses and contributions. This form no longer requires a signature.

NOTE: Prior to 09/30/2024, continue to use form SSA-8011-F3 to document a claimant or recipient’s statement about household expenses and contributions. This form no longer requires a signature.

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 Report of Contact page, (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 Report of Contact page, (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 LA 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 they are 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 a Report of Contact page 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 a Report of Contact (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.

Fax and store the SSA-8011-F3 in either eView or the Non-Disability Repository for Evidentiary Documents (NDRED) using the Evidence Portal (EP). You can access the Evidence Portal (EP) at View Evidence - Evidence Portal. Once the documentation is stored and viewed for content in either eView or NDRED by using the Evidence Portal (EP) there is no need to retain the documents.

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.

 

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0500835625
SI 00835.625 - SSA-8011 — Statement of Household Expenses and Contributions - 10/01/2024
Batch run: 10/01/2024
Rev:10/01/2024