SSA-8011-F3 Form PDF Details

When navigating the complexities of social security benefits, individuals often encounter the need to accurately report their household contributions and expenses. The Form SSA-8011-F3 plays a critical role in this process, serving as a tool for the Social Security Administration (SSA) to gather detailed information. It's designed to assess the eligibility of claimants and the correct benefit payment amounts by examining the monthly household expenses and the financial contributions made by or on behalf of the claimant. Detailed across four parts, this form requests specific figures on expenses ranging from food (excluding purchases made with food stamps) to shelter-related outlays, including rent or mortgage, utilities, and property insurance, among others. Additionally, it explores the contributions made towards these expenses by various household members and inquires about any unique arrangements, such as individuals paying specifically for their food or shelter. Completing this form accurately is crucial, not only for ensuring the integrity of the information provided under penalty of perjury but also because it directly impacts the determination of benefits entitlement and the amount disbursed. As such, the SSA-8011-F3 form embodies an essential step for claimants navigating the path to securing their deserved social security benefits, emphasizing the importance of transparently sharing household financial dynamics.

QuestionAnswer
Form Name SSA-8011-F3 Form
Form Length 3 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 45 sec
Other names form ssa 8011 f3, form ssa 8011, ssa form 8011, ssa form ssa 8011

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Form SSA-8011-F3 (08-2017) UF

Page 1 of 3

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SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0456

STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS

CLAIMANT'S / BENEFICIARY'S NAME

SOCIAL SECURITY NUMBER

NAME OF SPOUSE OR PARENT(S) OF INDIVIDUAL NAMED ABOVE

NAME OF PERSON MAKING THIS STATEMENT

The questions on this form are divided into four sections. Answer the questions where we have checked the block. Then sign the form and return to Social Security.

PART I - MONTHLY HOUSEHOLD EXPENSES

For household expenses that change from month to month, show the average monthly amount of money your household has

spent per month for the periodthrough.

For the household expenses that are usually the same from month to month (like rent), show the amount your household spent

per month as of

.

 

 

 

Write "0" under amount if your household has not spent any money for one of the expenses.

 

HOUSEHOLD EXPENSES

 

MONTHLY

 

 

TOTAL SPENT

 

 

 

 

 

 

 

1.

Food (Do not include food bought with food stamps.)

$

 

 

 

 

 

 

2.

Rent or Mortgage Payment

$

 

 

 

 

 

3.

Property Insurance (if not included in mortgage payment and if required by mortgage holder)

$

 

 

 

 

 

4.

Real property taxes (if not included in mortgage payment). Subtract any rebate or credit.

$

 

 

 

 

 

5.

Electricity

$

 

 

 

 

 

6.

Gas

$

 

 

 

 

 

7.

Heating fuel (wood, coal, oil, kerosene, etc.)

$

 

 

 

 

 

8.

Water

$

 

 

 

 

 

9.

Sewerage

$

 

 

 

 

10. Garbage Removal

$

 

 

 

 

 

PART II-CONTRIBUTIONS TO HOUSEHOLD EXPENSES

In the spaces below, show the amount of money the person(s) named gave for the household expenses listed in Part I. Provide your answer for the blocks we have checked.

NAME

AVERAGE MONTHLY AMOUNT GIVEN

AMOUNT GIVEN

from

through

in

 

 

 

 

 

 

$

 

$

 

 

 

 

 

$

 

$

 

 

 

 

 

$

 

$

 

 

 

 

Form SSA-8011-F3 (08-2017)

Page 2 of 3

 

 

PART III - OTHER ARRANGEMENTS

1.

Do(es)

eat every meal during the month some where else?

YES

 

 

2.

Do(es)

buy all his/her/their own food with his/her/their

YES

 

own money?

 

 

 

 

 

 

 

 

 

NO

NO

3.

Do(es)

pay a certain amount just for household food?

YES*

NO

 

 

 

 

 

 

*If "Yes" how much each month?

 

AMOUNT

 

 

 

 

 

 

Name

 

 

$

 

 

 

 

 

 

 

 

 

 

Name

 

 

$

 

 

 

 

 

 

 

 

 

 

Name

 

 

$

 

 

 

 

 

 

 

 

 

 

4.

Do(es)

pay a certain amount for the household shelter

YES*

NO

 

expenses (the expenses other than food)?

 

 

 

 

 

 

 

 

 

 

 

*If "Yes" how much each month?

 

AMOUNT

 

 

 

 

 

 

Name

 

 

$

 

 

 

 

 

 

 

 

 

 

Name

 

 

$

 

 

 

 

 

 

 

 

 

 

Name

 

 

$

 

 

 

 

 

 

 

 

 

 

PART IV-REMARKS-Use this space for any additional explanations.

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge.

SIGNATURE

Your Signature (First name, middle initial, last name)

Date (Month, Day, Year) Day Time Telephone No. (Include Area Code)

WITNESSES

If you have signed by mark (X), two witnesses to the signing who know you must sign below giving their full addresses.

1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

 

 

ADDRESS (Number and Street)

ADDRESS (Number and Street)

CITY,STATE, AND ZIP CODE

CITY,STATE, AND ZIP CODE

Form SSA-8011-F3 (08-2017)

Page 3 of 3

 

 

PRIVACY ACT STATEMENT

Collection and Use of Personal Information

Sections 1612(a)(2)(A) and 1631(e)(1)(A)-(B) of the Social Security Act, as amended, allow us to collect this information. We will use the information you provide to determine your eligibility for benefits and benefit payment amounts.

See Revised Privacy Act Statement Attached

Furnishing us this information is voluntary. However, failing to provide all or part of the information could prevent us from making an accurate decision on your claim and could result in the loss of benefits.

We rarely use the information you supply for any purpose other than what we state above. However, we may use the information for the administration of our programs including sharing information:

1.To comply with Federal laws requiring the release of information from our records (e.g., to the Government Accountability Office and Department of Veterans Affairs); and,

2.To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract with us).

A list of when we may share your information with others, called routine uses, is available in our Privacy Act System of Records Notices, 60-0089, entitled Claims Folders Systems, and 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits. Additional information about these and other system of records notices and our programs is available from our Internet website at www.socialsecurity.gov or at your local Social Security office.

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person’s eligibility for federally funded or administered benefit programs and for repayment of incorrect payments or delinquent debts under these programs.

See Revised PRA Statement Attached

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995 . You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at

1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

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This document requires particular details to be typed in, hence you must take your time to enter exactly what is expected:

1. It is important to complete the ssa 8011 correctly, therefore be mindful when filling in the parts comprising these blank fields:

Step number 1 of submitting social security form 8011

2. Now that the previous part is complete, it is time to put in the necessary particulars in HOUSEHOLD EXPENSES, MONTHLY TOTAL SPENT, Food Do not include food bought, Real property taxes if not, Water Sewerage Garbage, PART IICONTRIBUTIONS TO HOUSEHOLD, In the spaces below show the, NAME, AVERAGE MONTHLY AMOUNT GIVEN from, through, and AMOUNT GIVEN in so you can move on to the next part.

Step no. 2 in completing social security form 8011

3. Completing is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

social security form 8011 completion process explained (portion 3)

4. The form's fourth section arrives with these blank fields to consider: Form SSAF, PART III OTHER ARRANGEMENTS, Does, Does, Does, If Yes how much each month, Name, Name, Name, Does, If Yes how much each month, Name, eat every meal during the month, buy all hishertheir own food with, and pay a certain amount just for.

social security form 8011 writing process described (portion 4)

5. This final stage to finish this form is essential. Be sure you fill out the appropriate blanks, which includes Name, Name, PART IVREMARKSUse this space for, I declare under penalty of perjury, Your Signature First name middle, SIGNATURE, and WITNESSES, before submitting. Otherwise, it might contribute to a flawed and possibly incorrect document!

social security form 8011 conclusion process clarified (step 5)

People who work with this document generally make mistakes while filling out I declare under penalty of perjury in this section. Ensure that you read twice whatever you enter right here.

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