Information Collection

Individuals or Households

IC 9663 under ICR 200708-0960-017 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.