Information Collection

Function Report - Adult

IC 9735 under ICR 200608-0960-008 · OMB 0960-0681.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3373-BK Function Report - Adult	Form and Instruction
SSA-3373 Function Report - Adult (Version with Proposed Revisions New SSA-3373 (0960-0681).doc	Form and Instruction
SSA-3373-BK Function Report - Adult (Current Version with no Revisio Old SSA-3373 (0960-0681).pdf	Form and Instruction

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 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-3373-BK	Function Report - Adult (Current Version with no Revisions)	Old SSA-3373 (0960-0681).pdf		No		Paper Only
Form and Instruction	SSA-3373	Function Report - Adult (Version with Proposed Revisions)	New SSA-3373 (0960-0681).doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,005,367

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	4,005,367	0	0	4,005,367
Annual IC Time Burden (Hours)	4,005,367	1,001,342	1,001,341	2,002,684
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.