Function Report - Adult

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0681 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3373 Function Report - Adult Form and Instruction
SSA-3373 Function Report -- Adult SSA-3373-BK - Revised Version.pdf Form and Instruction
SSA-3373-BK - Current Version.pdf Current SSA-3373-BK IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Function Report - Adult	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-3373	Function Report -- Adult	SSA-3373-BK - Revised Version.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: 1,734,635	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	1,734,635	-351,086	2,085,721
Annual IC Time Burden (Hours)	1,763,546	-356,937	2,120,483
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-3373-BK	SSA-3373-BK - Current Version.pdf	07/26/2018

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