POMS Reference

This change was made on Apr 24, 2018. See latest version.
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SI 00835.625: SSA-8011 — Statement of Household Expenses and Contributions

changes
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  • Effective Dates: 03/13/2013 - Present
  • Effective Dates: 04/24/2018 - Present
  • 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 consumption;
  • * separate purchase of food; or
  • * earmarked contributions.
  • 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.").
  • * Review with the respondent the information provided by the claimant, located on the Household of Another page;
  • * If the information received from the respondent is not consistent with the claimant’s statements, update the Household of Another page accordingly and document on a DROC Screen, (e.g., “Contacted householder Frank Johnson, information was not consistent, updated the Household of Another page.”); 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 the Household of Another page.").
  • 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;
  • * For MSSICS cases, document the information on the DROC screen as in SI 00835.625B.1. in this section, and update the Household of Another page(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
  • Self-explanatory.
  • 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
  • Self-explanatory.
  • D. Exhibit — Form SSA-8011-F3
  • To view this form, go to SSA-8011–F3.