Information Collection

Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912

IC 9663 under ICR 200608-0960-004 · OMB 0960-0635.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3380-BK Function Report--Adult--Third Party Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912	Form and Instruction
Form SSA-3380-BK Function Report--Adult--Third Party (Revised Version) Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912	Form and Instruction
SSA-3380-BK Function Report--Adult--Third Party SSA-3380-BK.pdf	Form and Instruction
SSA-3380-BK Function Report--Adult--Third Party (Revised Version) 3380.pdf	Form and Instruction

IC Title:

Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912

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 404.1512 20 CFR 416.912

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3380-BK				No		Paper Only
Form and Instruction	SSA-3380-BK				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,000,000	0	0	1,000,000
Annual IC Time Burden (Hours)	1,000,000	250,000	250,000	500,000
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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