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OMB Control No: 0960-0456	ICR Reference No: 202410-0960-010
Status: Active	Previous ICR Reference No: 202201-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Household Expenses and Contributions
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/22/2024
	Date Received in OIRA: 10/17/2024
Terms of Clearance: In accordance with 5 CFR 1320, this information collection is approved.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2026	12/31/2026	12/31/2026
Responses	419,759	0	419,759
Time Burden (Hours)	314,819	0	314,819
Cost Burden (Dollars)	0	0	0

Abstract: 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.

Authorizing Statute(s): US Code: 42 USC 1382a Name of Law: Social Security Act
US Code: 42 USC 1383 Name of Law: Social Security Act

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 56746	10/12/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 139	01/03/2022
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Statement of Household Expenses and Contributions - Paper Form	SSA-8011-F3
Statement of Household Expenses and Contributions - SSI Claims System

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	419,759	419,759
Annual Time Burden (Hours)	314,819	314,819
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: 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.

Annual Cost to Federal Government: $2,219,748

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

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