Get SSA-8011-F3 2017-2024

Provide your answer for the blocks we have checked. AMOUNT GIVEN AVERAGE MONTHLY AMOUNT GIVEN NAME from In EF 07-2007 Form SSA-8011-F3 07-2007 Page 1 PART III - OTHER ARRANGEMENTS Do es meal during the month some where else his/her/their own food with his/her/their own money eat every amount just for household food YES pay a certain If Yes how much each month NO buy all AMOUNT amount for the household shelter expenses The expenses other than food PART IV-REMARKS-Use this space for any additional explanations. FORM APPROVED OMB No. 0960-0456 SOCIAL SECURITY ADMINISTRATION STATEMENT OF HOUSEHOLD EXPENSES AND CONTRIBUTIONS CLAIMANT S / BENEFICIARY S NAME NAME OF SPOUSE OR PARENT S OF INDIVIDUAL NAMED ABOVE NAME OF PERSON MAKING THIS STATEMENT The questions on this form are divided into four sections. Total Household Expenses I declare under penalty of perjury that I have examined all the information on this form and on any accompanying statements or forms and it is true and correct to the best of my knowledge. Answer the questions where we have checked the block. Then sign the form and return to Social Security. PART I - MONTHLY HOUSEHOLD EXPENSES For household expenses that change from month to month show the average monthly amount of money your household has spent per month for the period through. Answer the questions where we have checked the block. Then sign the form and return to Social Security. PART I - MONTHLY HOUSEHOLD EXPENSES For household expenses that change from month to month show the average monthly amount of money your household has spent per month for the period through. For the household expenses that are usually the same from month to month like rent show the amount Write 0 under amount if your household has not spent any money for one of the expenses. MONTHLY AMOUNT SPENT HOUSEHOLD EXPENSES 1. Food Do not include food bought with food stamps. 2. Rent or Mortgage Payment 3. Property Insurance if not included in mortgage payment and if required by mortgage holder 4. Real property taxes if not included in mortgage payment. Subtract any rebate or credit. 5. Electricity 6. Gas 7. Heating fuel wood coal oil kerosene etc* 8. Water 9. Sewerage 10. Garbage Removal PART II-CONTRIBUTIONS TO HOUSEHOLD EXPENSES In the spaces below show the amount of money the person s names gave for the household expenses listed in Part I. SIGNATURE Your Signature First name middle initial last name Date Month Day Year SIGN HERE Day Time Telephone No* Include Area Code WITNESSES If you have signed by mark X two witnesses to the signing who know you must sign below giving their full addresses. 1. SIGNATURE OF WITNESS ADDRESS Number and Street CITY STATE AND ZIP CODE Page 2 PRIVACY ACT NOTICE Section 1631 e 1 of the Social Security Act authorizes us to collect the information requested on this form to decide if the individual s named can receive Supplemental Security Income SSI payments from us and if so how much. The individual or the individual s representative has given permission to us to obtain this information* You do not have to give us this information but if you do not it may adversely affect the individual s eligibility for or amount of SSI.