Information Collection

Statement of Household Expenses and Contributions

IC 9338 under ICR 200611-0960-002 · OMB 0960-0456.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0456 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-8011-F3 (Revis Statement of Household Expenses and Contributions Form
SSA-8011-F3 (Revis Statement of Household Expenses and Contributions Revised SSA-8011-F3.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Household Expenses and Contributions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1130-416.1184

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-8011-F3 (Revised Version)	Statement of Household Expenses and Contributions	Revised SSA-8011-F3.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	400,000	400,000
Annual IC Time Burden (Hours)	100,000	100,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.