Private Sector

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⚠️ Notice: This information collection may be referencing outdated material.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 Private Sector Form and Instruction
SSA-3380 Function Report--Adult--Third Party ssa3380(revised).pdf Form and Instruction
ssa3380.pdf SSA-3380 -- Current Version IC Document

Information Collection (IC) Details

IC Title:	Private Sector	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	ssa3380(revised).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: 527,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-527,000	527,000
Annual IC Time Burden (Hours)	-535,783	535,783
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3380 -- Current Version	ssa3380.pdf	07/10/2012

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