Statement of Household Expenses and Contributions

OMB Control No: 0960-0456	ICR Reference No: 200611-0960-002
Status: Historical Active	Previous ICR Reference No: 200402-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Household Expenses and Contributions
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/01/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/30/2007
Terms of Clearance: Approved consistent with the revised collection of (4/24/07) under the following conditions: 1) SSA shall clarify “Write ‘0’ under amount if your household has not spent any month for one of the expenses” to instruct the respondent to write 0 for that particular expense. 2) SSA shall clarify that for questions 3 and 4 in part III that the “if yes” question is to be answered only for a “yes” answer to question 3 or 4, respectively. two clarifications to be made on the form prior to circulation.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2010	36 Months From Approved	04/30/2007
Responses	400,000	0	400,000
Time Burden (Hours)	100,000	0	100,000
Cost Burden (Dollars)	0	0	0

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Abstract: SSA needs the information about household expenses and contributions, which is collected on Form SSA-8011-F3, to determine whether the claimant or beneficiary receives in-kind support and maintenance. This is necessary to determine the claimant's or beneficiary's eligibility for Supplemental Security Income (SSI) and the amount of benefits payable. This form is not used for all claims and post eligibility determinations; rather, it is used only when it is necessary to document in-kind support and maintenance and only in cases where the householder's corroboration is needed. Respondents are SSI applicants and/or beneficiaries.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 64327	11/01/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 2081	01/17/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name Statement of Household Expenses and Contributions SSA-8011-F3 (Revised Version) Statement of Household Expenses and Contributions

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	400,000	400,000	0	0	0	0
Annual Time Burden (Hours)	100,000	100,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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:

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Annual Cost to Federal Government: $1,232,000

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Elizabeth Davidson 411-965-0454 [email protected]

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Common Form ICR:  No

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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:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(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;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
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.
Certification Date: 01/30/2007

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