TN 117 (12-23)

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 Part 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 Part 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 their 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.

Question 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 their 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 they live 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 their 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 their spouse has ownership interest or rental liability for the place where 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”.

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SI 00835.600 - SSA-8006-F4 — Statement of Living Arrangements, In-Kind Support and Maintenance - 12/13/2023
Batch run: 12/13/2023