Form SSA-8011-F3: Statement of Household Expenses and Contributions

The questions on this form are divided into four sections. Answer the questions where Social Security has checked the block.

Enter the claimant's/beneficiary's name and social security number, the name of spouse or parent(s) of the individual named in the claimant's/beneficiary's name box, and the name of person making this statement.

For household expenses that change from month to month, show the average monthly amount of money your household has spent per month for the period through.

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.

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.

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

PART 2 - 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 1. Provide your answer for the checked blocks.

PART 3 - OTHER ARRANGEMENTS. 1. Do(es) eat every meal during the month somewhere else? YES or NO

2. Do(es) buy all his/her/their own food with his/her/their own money? YES or NO

3. Do(es) pay a certain amount just for household food? If "Yes" how much each month? YES or NO

4. Do(es) pay a certain amount for the household shelter expenses (the expenses other than food)? If "Yes" how much each month? YES or NO

PART 4 - REMARKS. Use this space for any additional explanations.

Print the Name of Person Completing the Form, the Mailing Address, the Date and the Telephone Number (Include area code).

Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, or submit or causes to be submitted any false statement or document knowing the same to contain any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.

Then return to Social Security.