TN 63 (12-08)
SI 00835.625 SSA-8011 — Statement of Household Expenses and Contributions
A. Policy for use of the SSA-8011
1. When to use Form SSA-8011
Use the SSA-8011-F3 to verify the following items as required by
SI 00835.140 - SI 00835.200 and SI 00835.340:
household operating expenses;
the individual's contribution to household operating expenses;
separate purchase of food; or
NOTE: Use the SSA-8011-F3 when it is not feasible to document the file solely on MSSICS.
2. Exception—when an SSA-8011 is not required
If the representative payee has completed Part II of the SSA-8006-F4 on the individual's behalf and is the householder, an SSA-8011-F3 is not necessary.
3. Who provides information on the SSA-8011
The householder or knowledgeable adult member of the individual's household (other than the individual's spouse) provides the information.
B. Procedure for interviewing the householder/knowledgeable adult respondent
1. Respondent is at the interview or on the telephone
If the respondent is at the interview or on the telephone:
Review with the respondent the information provided by the claimant, located on the LOHH screen;
If the information received from the respondent is not consistent with the claimant’s statements, update the LOHH screen accordingly and document on a DROC Screen, (e.g., “Contacted householder Frank Johnson, information was not consistent, updated LOHH screen.”); or
If the claimant’s and respondent’s statements are consistent, document on a DROC screen, (e.g., “Contacted householder Frank Johnson, information consistent with LOHH screen.").
2. Respondent is not at the interview and not available by telephone:
If the respondent is not at the interview and not available by telephone, use the SSA-8011-F3:
Mark the SSA-8011 to indicate which questions to answer, about whom the information is requested, and the living arrangement period for which information is being requested;
Ask the claimant/recipient to have the respondent complete the remainder of the form and sign it; and
Tell the claimant/recipient that he or she is responsible for the return of the form to the field office. Use the SSA-L8009-U3 (SI 00601.120) in initial claim situations and the SSA-L8003-U2 (SI 02306.020) for PE situations. Provide a postage-paid return envelope for the respondent to use.
3. Electronic documentation requirements for the paper SSA-8011
If a paper SSA-8011-F3 is received from the respondent:
For MSSICS cases, document the information on the DROC screen as in SI 00835.625B.1. in this section, and update the LOHH screen(s) accordingly;
If the SSA-8011 information cannot be documented on DROC (e.g., not a MSSICS claim), fax the SSA-8011 into the appropriate electronic folder;
Do not retain the paper form after the issue has been documented electronically.
For more information on storing forms electronically refer to GN 00301.322 “Retention of Paper Material After Faxing into Either the eDIB folder or Claims Folder using NDRed”.
C. Procedure for completing Form SSA-8011
1. Identification lines
NOTE: Due to privacy concerns, do not include claimant’s entire SSN when completing the SSA-8011-F3.
2. Part I — Household expenses
Check the block to indicate Part I should be completed.
a. Averaging period
In the spaces provided, indicate the period for which the fluctuating expenses must be averaged. (For rules on the averaging period, refer to SI 00835.475.)
NOTE: If it is necessary to document more than one averaging period for expenses, use additional SSA-8011-F3’s as supplements.
b. Month for non-fluctuating expenses
In the space provided, indicate the month for which a determination is being made.
c. Food item
Line through “Food” if the claimant/recipient alleges separate consumption /purchase of food.
3. Part II — Contributions
If appropriate, check the block to indicate Part II should be completed.
a. Contributors' names
Enter the name(s) of the individual(s) alleged to be contributing (claimant/ recipient or deemors).
b. Checking the blocks
Check the appropriate block(s) to request the average of contributions and/or an amount paid in a particular month. Use both blocks when a significant change in contributions must be documented as well as average contributions for another month's determination. (This should rarely be necessary.)
c. Averaging period
Enter the months for which the average contribution is solicited. For rules on averaging contributions, see SI 00835.480.
NOTE: If it is necessary to document more than one averaging period for contributions, use additional SSA-8011-F3 forms as supplements.
d. Month of significant change
In the “Amount given in” block, enter the month in which there is a significant change in the individual's contribution that did not continue. For example, enter the month a prepayment is alleged.
4. Part III — Other arrangements
If appropriate, check the block(s) in Part III that describes the alleged arrangement for food and shelter and enter the name(s) of the person(s) who has the arrangement (claimant/recipient or deemors).
5. Part IV — Remarks
D. Exhibit — Form SSA-8011-F3
To view this form, go to SSA-8011–F3.