In accordance
with 5 CFR 1320, this information collection is approved.
Inventory as of this Action
Requested
Previously Approved
12/31/2026
12/31/2026
12/31/2026
419,759
0
419,759
314,819
0
314,819
0
0
0
SSA bases eligibility for Supplemental
Security Income (SSI) on the needs of the recipient. In part, we
assess need through determining the amount of income a recipient
receives. This income includes in-kind support and maintenance in
the form of food and shelter home owners provide. SSA uses Form
SSA-8011-F3, Statement of Household Expenses and Contributions, to
determine whether the claimant or recipient receives in-kind
support and maintenance. This is necessary to determine: (1) The
claimant’s or recipient’s eligibility for SSI, and (2) the SSI
payment amount. SSA only uses this form in cases where SSA needs
the householder’s (head of household) corroboration of in-kind
support and maintenance. The SSA-8011-F3 provides information,
which could affect SSI eligibility and payment amount. An SSA
claims specialist collects the information on Form SSA-8011-F3
through telephone contact with the respondents, or through
face-to-face interviews. The claims specialist records the
information in our electronic SSI Claims System. When we use this
procedure, we do not use a paper Form SSA-8011-F3, and we do not
require a wet signature, rather we request verbal attestation.
However, for those few instances when we use a paper form, we
ensure the appropriate person, i.e., the householder, signs the
form, and then the claims specialist documents the information in
the SSI Claims System; faxes the form into the appropriate
electronic folder; and shreds the form. Respondents are
householders of homes in which an SSI applicant or recipient
resides. We are submitting this Non-Substantive Change Request to
remove the signature requirement and replacing the Penalty of
Perjury Statement with a Penalty of Perjury Warning.
US Code:
42
USC 1382a Name of Law: Social Security Act
US Code: 42
USC 1383 Name of Law: Social Security Act
When we last cleared this IC in
2018, the burden was 106,314 hours. However, we are currently
reporting a burden of 104,940 hours. This decrease stems from an
decrease in the number of responses from 425,258 to 419,759. In
addition, we also separated out the paper modality from the SSI
Claims System modality. There is no change to the burden time per
response. Although the number of responses changed, SSA did not
take any actions to cause this change. Finally, as per OMB’s
request, we included the 30-minute travel time to a field office in
our burden calculations, which also increased the burden.
$2,219,748
No
Yes
Yes
No
No
No
No
Faye Lipsky 410 965-8783
faye.lipsky@ssa.gov
No
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Form SSA-8011-F3 Statement of Household Expenses and Contributions - Paper Form
Justification for Non-substantive Change 0960-0456.docx
Statement of Household Expenses and Contributions - SSI Claims System