Individuals or Households

Function Report - Adult Third Party

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0635 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3380 Individuals or Households Form and Instruction
SSA-3380 Function Report -- Adult Third Party SSA-3380 -- Originally Approved in 2004 (requesting reinstatement per the Addendum).pdf Form and Instruction
PRA.doc PRA Statement IC Document

Information Collection (IC) Details

IC Title:	Individuals or Households	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 416.912 20 CFR 404.1512

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3380	Function Report -- Adult Third Party	SSA-3380 -- Originally Approved in 2004 (requesting reinstatement per the Addendum).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: 500,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	500,000	-500,000	1,000,000
Annual IC Time Burden (Hours)	500,000	-500,000	1,000,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
PRA Statement	PRA.doc	08/23/2007

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