Currently Approved SSA-3373 (from 2006)

FUNCTION REPORT – ADULT – Form SSA-3373-BK
READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
IF YOU NEED HELP
If you need help with this form, complete as much of it as you can and call the phone
number provided on the letter sent with the form, or contact the person who asked
you to complete the form. If you need the address or phone number for the office
that provided the form, you can get it by calling Social Security at 1-800-772-1213.
HOW TO COMPLETE THIS FORM
The information that you give us on this form will be used by the office that makes
the decision on your disability claim or case. You can help them by completing as
much of the form as you can.
It is important that you tell us about your activities and your abilities and about any
changes in your activities or your abilities since your illnesses, injuries, or conditions
and any related symptoms first bothered you.
•
•
•
•

•

•
•

Print or write clearly.
DO NOT LEAVE ANSWERS BLANK. If you do not know the answer or the
answer is “none” or “does not apply,” please write “don’t know,” or “none,” or
“does not apply.”
Do not ask a doctor or hospital to complete this form.
Be sure to consider any symptoms related to your illnesses, injuries, or
conditions, such as pain, fatigue, shortness of breath, weakness, or
nervousness, when answering questions about how your illnesses, injuries, or
conditions affect your activities or abilities.
When a question refers to “you” or “your,” it refers to the person who is
applying for or receiving disability benefits. If you are filling out the report for
that person, please provide the information about him or her. Use the space
in Section D to explain why the person is not completing the form himself or
herself.
Be sure to explain an answer if the question asks for an explanation, or if you
think you need to explain an answer.
If you need more space to answer any questions or want to tell us more about
an answer, please use the “REMARKS” section, beginning on Page 13 or
attach a blank sheet of paper, and show the number of the question being
answered. If you do attach a blank sheet of paper, please put your name and
Social Security Number at the top of the sheet so that we can make sure we
keep the sheet with your claims file.

REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON COMPLETING THIS
FORM AND THE DATE THE FORM WAS COMPLETED ON PAGE 14

The Privacy Act
The Social Security Administration is authorized to collect the information on this form
under sections 205(a) and (b), 223(d) and 1631(e)(1) of the Social Security Act. The
information on this form is needed by Social Security to make a decision on your claim or
case. While giving us the information on this form is voluntary, failure to provide all or part
of the requested information could prevent an accurate or timely decision on your claim or
case. Although the information you furnish is almost never used for any purpose other than
making a determination about your disability or continuing disability, such information may
be disclosed by the Social Security Administration as follows: (1) to enable a third party or
agency to assist Social Security in establishing rights to Social Security benefits and/or
coverage; (2) to comply with Federal Laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and the Department of
Veterans Affairs); and (3) to facilitate statistical research and such activities necessary to
assure the integrity and improvement of the Social Security programs (e.g., to the Bureau of
the Census and private concerns under contract to Social Security).
We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government
agencies. Many agencies may use matching programs to find or prove that a person qualifies
for benefits paid by the Federal government. The law allows us to do this even if you do not
agree to it.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security offices. If you want to learn more about this,
contact any Social Security office.
The Paperwork Reduction Act
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number. We
estimate that it will take you about 60 minutes to read the instructions, gather the facts, and
answer the questions. SEND THE COMPLETED FORM TO THE OFFICE THAT
REQUESTED IT. If you do not have that address, you may call Social Security at
1-800-772-1213. You may send comments on our time estimate above to: SSA, 6401 Security
Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.

AFTER COMPLETING THIS FORM, REMOVE THIS SHEET AND
KEEP IT FOR YOUR RECORDS.

OMB No. 0960-0681

SOCIAL SECURITY ADMINSTRATION_______________________________

FUNCTION REPORT – ADULT

SECTION A – GENERAL INFORMATION
1. NAME OF PERSON APPLYING FOR OR RECEIVING DISABILITY BENEFITS
(First, Middle, Last)___________________________________________________________
2. SOCIAL SECURITY NUMBER

___ - __ - ____

3. YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you
can be reached, please tell us the name and daytime number of a person with whom we
can leave a message for you.)
___ _______________
Area Code

Your Number

Message Number

None

Phone Number

________________________________________________________________________
4. LIST any symptoms related to your illnesses, injuries, or conditions ________________
______________________________________________________________________
______________________________________________________________________
5. a. Do you live in a: (Check where you live NOW)
1. House?
4. Nursing Home?
2. Apartment?
5. Shelter?
3. Boarding House?
6. Group Home?
7. Other?
If you checked “Other,” please DESCRIBE where you live ____________________________
_____________________________________________________________________________
b: Do you live (Check your CURRENT living arrangement)
1. Alone?
3. With Friends?
2. With Family?
4. Other?
If you checked “Other,” please DESCRIBE your living arrangement _____________________
______________________________________________________________________________
SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)
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c. Has there been any change in where you live or your living arrangements because of your
illnesses, injuries, or conditions?
YES NO
If “NO,” go to Section B.
If “YES,” please DESCRIBE what has changed.________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________
d. What is the reason for the change? __________________________________________
______________________________________________________________________
______________________________________________________________________
SECTION B – INFORMATION ABOUT YOUR ABILITIES
6. a. Do your illnesses, injuries, or conditions affect your ability to:
1. Lift?
YES NO
8. Kneel?
2. Carry?
YES NO
9. Crawl?
3. Stand?
YES NO
10.Reach?
4. Walk?
YES NO
11.Use Your Hands?
5. Sit?
YES NO
12. See?
6. Climb Stairs?
YES NO
13. Hear?
7. Bend?
YES NO
14. Talk?

YES
YES
YES
YES
YES
YES
YES

NO
NO
NO
NO
NO
NO
NO

b. If you checked “YES” for an activity, please LIST the number of the activity and EXPLAIN
HOW and WHY your illnesses, injuries, or conditions affect your ability to do that activity.
For example, before you were able to lift [how many pounds], but now you can lift [how many
pounds] because your shoulder is weak; before you were able to walk [how far], but now you
can walk [how far] because you get tired; you used to wear shoes that laced, but now you only
wear slip-on shoes because your fingers are too stiff to tie laces. Please be as SPECIFIC as
you can._____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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c. For each of the activities below, please check the box that best describes what you can do
1. I can walk for 0 1
2
3
4
5
6
7
8 hours before
having to rest.
2. I can stand for
0
1
2
3
4
5
6
7
8 hours
before having to rest.
3. I can sit for 0
1
2
3
4
5
6
7
8 hours before
having to change position.
4. I can bend Frequently
Occasionally Never
5. I can lift
10
20
30
40
50
pounds frequently
6. I can lift
10
20
30
40
50
pounds occasionally
7. I can reach my arms out and up
Frequently
Occasionally Never
d. Do you USE:
1. Crutches?
YES NO
6. Glasses/Contact Lenses? YES NO
2. Cane?
YES NO
7. Hearing Aid?
YES NO
3. Walker?
YES NO
8. Artificial Arm or Leg? YES NO
4. Brace/Splint?
YES NO
9. Artificial Voice Box?
YES NO
5. Wheelchair?
YES NO
10. Other Assistive Device? YES NO
If you checked “YES” to 10, please DESCRIBE the device. ______________________________
_______________________________________________________________________________
_______________________________________________________________________________
e. If you do not use any type of assistive device, go to g.
If you use an assistive device, LIST each type of assistive device you use, DESCRIBE when you
use it, and TELL if it does or does not help you in your daily activities.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
f. If the assistive device(s) was prescribed, TELL who prescribed it and the DATE it was
prescribed.______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
g. Have your illnesses, injuries, or conditions affected your ability to:
1. Pay attention?
YES NO
2. Understand
YES NO
3. Finish something you start?
YES NO
4. Read a newspaper, magazine, or book?
YES NO
5. Watch a movie?
YES NO
6. Follow written instructions?
YES NO
7. Follow spoken instructions?
YES NO
8. Handle changes in your routine?
YES NO
9. Handle stress?
YES NO
Form SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)

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h. If you checked “YES” for any activity in g., please LIST the activity and EXPLAIN
WHAT has changed because of your illnesses, injuries, or conditions.____________________
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
7. MEDICATION, TREATMENT, OR OTHER METHOD
a. Do you take any prescription or non-prescription medications for your illnesses, injuries,
conditions, or symptoms?
YES NO
If “NO,” go to b.
If “YES,” please answer 1., 2., and 3.
1. Do you take the medications in the dosages and at the frequency instructed? YES NO
If “NO,” please EXPLAIN why not and at WHAT dosage and frequency you take the
medication. ________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
2. Do you need help or reminders to take your medications? YES
NO
If “NO,” go to 3.
If “YES,” what help or reminders do you need? Please DESCRIBE. __________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
3. Has the medication affected your ability to do things (for example, after taking your
medication you can bend more easily; the medication makes you sleepy)?
YES NO
If “NO,” go to b.
If “YES,” please EXPLAIN the effect the medication you take for your illnesses, injuries,
or conditions has on your ability to do things.______________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
b. Is there any treatment, other than medication, (for example, acupuncture or physical therapy) or
other method (for example, lying flat on your back or changing position) that you use now or that you
have used in the past for your illnesses, injuries, conditions or symptoms? YES NO
If “NO,” go to Section C.
If “YES,” please answer 1., 2., 3., and 4:
1. For each treatment or other method you use or have used, LIST the TYPE and the DATE you
started the treatment or other method and the DATE treatment ended. If you are still taking the
treatment or using the other method, show “ongoing.”__________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Form SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)

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2. Was the treatment or other method recommended by a doctor or other health care professional
who treated or examined you? YES NO
If “NO,” go to 3.
If “YES,” please LIST the treatment or other method, the NAME of the doctor or other health
care professional who recommended it, and HOW OFTEN you take the treatment or use the
other method.__________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. Do you need help or reminders to follow your treatments or other methods? YES NO
If “NO,” go to 4.
If “YES,” what kind of help or reminders do you need? Please DESCRIBE. ______________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Have the treatments or other methods you use or have used affected your ability to do things
(for example, changing positions relieves pain in your back; the treatments leave you tired)?
YES NO.
If “NO,” go to Section C.
If “YES,” please EXPLAIN the effect the treatments or other methods you use for illnesses,
injuries, or conditions have on your ability to do things. Please be SPECIFIC.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SECTION C – INFORMATION ABOUT YOUR DAILY ACTIVITIES
8. PERSONAL CARE
a. Do your illnesses, injuries, or conditions affect your ability to:
1. Dress?
YES NO
5. Shave?
YES NO
2. Shower or bathe? YES NO
6. Feed yourself?
YES NO
3. Care for hair?
YES NO
7. Use a toilet?
YES NO
4. Care for teeth?
YES NO
8. Do some other
YES NO
personal care activity?
b. For each item that you checked “YES,” LIST the number of the item and DESCRIBE how
your illnesses, injuries, or conditions affect that activity (for example, it takes more time to dress,
you have a simpler hair style, you changed to an electric razor).____________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Form SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)

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c. Do you need help or reminders to care for your personal needs? YES NO
If “NO,” go to question 9.
If “YES,” what kind of help or reminders do you need? ____________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
9. Do your illnesses, injuries, or conditions affect your sleep? YES NO
If “NO,” go to question 10.
If “YES,” please EXPLAIN.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
10. Do you take care of:
a. Another person (for example, your spouse, child, grandchild, parent, or friend)?
YES NO
NEVER DID THIS
b. A pet or other animal?
YES NO
NEVER DID THIS
c. If you answered “NO” or “NEVER DID THIS,” to a. and b., go to question 11.
If you answered “YES” to a. or b:
1. Who or what do you take care of? _______________________________________________
______________________________________________________________________________
2. What do you do for them? ______________________________________________________
______________________________________________________________________________
3. Does someone help you take care of the other person, pet or other animal? YES NO
If “NO,” go to question 11.
If “YES,” please answer a. and b.
a. Who helps you? _________________________________________________________
_______________________________________________________________________________
b. How do they help you? ____________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
11. Has there been any change in what you can do because of your illnesses, injuries, or conditions?
YES NO
If “NO,” go to question 12.
If “YES,” please EXPLAIN.
_______________________________________________________________________________
_______________________________________________________________________________
Form SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)

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12. GETTING AROUND
a. Do you go outside your home alone? YES NO
If “YES,” go to b.
If “NO,” please EXPLAIN why you do not go out alone.___________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
b. When you go outside your home, do you (Check ALL that apply)
1. Walk?
4. Use public transportation?
2. Drive yourself?
5. Ride a bicycle?
3. Go as a passenger in a car, truck, or other private vehicle? 6. Other?
If you checked “Other’ please DESCRIBE. _____________________________________
____________________________________________________________________________
____________________________________________________________________________
c. If you checked b.2, please TELL how OFTEN you drive and how FAR you can drive
comfortably.___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
d. Even if you do not drive yourself when you go outside your home, can you drive?
YES NO
1. If “YES,” please EXPLAIN why you do not drive yourself when you go outside your
home (for example, you do not have a current driver’s license).______________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
2. If “NO,” please EXPLAIN why you cannot drive (for example, you never learned how
to drive). _________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
e. Has there been any change in how you travel to places outside your home (for example, to a
doctor, shopping, visiting) because of your illnesses, injuries, or conditions? YES
NO
If “NO,” go to question 13
If “YES,” please DESCRIBE the change._______________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Form SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)

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13. MONEY
a. Are you able to:
1. Use your money by yourself?
YES NO
2. Count change?
YES NO
3. Handle a savings account?
YES NO
4. Use checks or money orders?
YES NO
If you are able to do all of the listed activities, go to b.
For any item that you checked “NO,” please EXPLAIN why you are not able to do the
activity. __________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
b. Has there been any change in your ability to manage your money or pay your bills because of
your illnesses, injuries, or conditions?
YES NO
If “NO,” go to question 14.
If “YES,” please DESCRIBE the change._______________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
14. MEALS
a. Do you prepare your own meals? YES
NO
If ”YES,” go to b.
If “NO,” please EXPLAIN why you do not prepare your own meals.__________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
b. What meals do you usually prepare? (Check ALL that apply)
1. Breakfast
2. Lunch
3. Dinner
c. Normally do you (Check the answer that is MOST OFTEN true)
1. Order take-out food?
2. Make simple meals, needing little preparation (dry cereal and milk, sandwiches, canned
soup)?
3. Use ingredients requiring peeling or slicing vegetables, frying, baking or roasting meat,
or following a recipe?
d. Has there been any change in the way you prepare meals (for example, the type of meals you
prepare, the time you spend preparing meals, how often you prepare meals) because of your
illnesses, injuries, or conditions? YES
NO
If “NO,” go to question 15.
If “YES,” pleases DESCRIBE the changes. _____________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Form SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)

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15. HOUSE AND YARD WORK
a. Do you do any house or yard work (for example, wash dishes, laundry, ironing, dusting,
vacuuming, household repairs, home improvement projects, mow a lawn, gardening)?
YES NO
If “NO,” please EXPLAIN why not. ___________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
If “YES,” LIST the household or yard work that you do.____________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
b. Has there been a change in the way you do the house or yard work listed in 15.a. or in the time
it takes you to do the work because of your illnesses, injuries, or conditions? YES NO
If “NO,” go to c.
If “YES,” please LIST any house or yard work you do in which there has been a change
and DESCRIBE the change. Please be SPECIFIC. _______________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________
c. Do you need help, reminders, or encouragement to do any of the house or yard work you do?
YES NO
If “NO,” go to question 16.
If “YES,” LIST each activity for which you need help, reminders, or encouragement,
DESCRIBE why you need the help, reminders, or encouragement, and LIST who
provides the help, reminders, or encouragement.__________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
16. SHOPPING
a. Do you do any shopping for yourself or others?
YES NO
If “NO,” go to d.
If “YES,” do you shop: (Check “YES” for ALL that apply)
1. In the stores?
YES NO
3. By mail (catalogue)?
2. By phone?
YES NO
4. By computer?
Form SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)

YES
YES

NO
NO
Page 9

b. Do you shop for:
1. Groceries? YES
NO
If “NO,” go to 2.
If “YES,” HOW OFTEN do you shop for groceries? _____________________________
___________________________________________________________________________
___________________________________________________________________________
2. Clothing (for yourself or others)? YES
NO
If “NO,” go to 3.
If “YES,” HOW OFTEN do you shop for clothing? _______________________________
____________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
3. Other shopping?
YES NO
If “NO,” go to d.
IF “YES,” DESCRIBE what you shop for and HOW OFTEN you do this type of
shopping?_________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
c. Has there been any change in the way you shop (for example, you now shop more by phone),
or in your shopping habits (for example, you shop less often) because of your illnesses, injuries,
or conditions? YES NO.
If “NO,” go to question 17.
If “YES,” please DESCRIBE the change Please be SPECIFIC. ____________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________
d. If you do not shop for yourself or others, is this a change?
YES NO
If “NO,” go to question 17.
If “YES,” please DESCRIBE the change. Please be SPECIFIC. ____________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
17. SOCIAL ACTIVITIES
a. Do you do things with other people (in person, on the phone, on the computer, etc.)?
YES NO
If “NO,” go to c.
If “YES,” please DESCRIBE the kinds of things you do with other people.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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b. How often do you do each of the things you described in a.?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
c. Are there things you do outside your home or places you go on a regular basis (religious
services, community center, sports events, social groups, visit with family or friends, etc.)?
YES NO.
If “NO,” go to e.
If “YES,” for each thing you do or place you go, TELL how often you do the activity or go
to the place and what you do there (for example, weekly Sunday morning church service,
monthly community meeting-treasurer, watch weekly little league games during season).
______________________________________________________________________________
______________________________________________________________________________
d. Has there been any change in your social activities because of your illnesses, injuries, or
conditions? YES NO
If “YES,” DESCRIBE the change. Please be SPECIFIC.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
e. Do you get along with others (family, friends, neighbors, etc.)?
YES
NO
If “YES,” go to f.
If “NO” please EXPLAIN why not. Please be SPECIFIC.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
f. Do you get along with authority figures (for example, police, a boss, landlord, or teacher)?
YES
NO
If “YES,” go to g.
If “NO,” please EXPLAIN in what way you do not get along with authority figures._____
___________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
g. Have you ever quit, been fired, or been laid off from a job because of your injuries, illnesses,
or conditions? YES NO
If “NO,” go to question 18.
If “YES,” please EXPLAIN what happened._____________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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18. HOBBIES AND INTERESTS
a. Do you have any hobbies or interests (for example, reading, watching TV, sewing, playing, or
watching sports, bingo, playing cards, fishing, hunting, camping, gardening, or computer)?
YES NO
NEVER HAD ANY HOBBIES OR INTERESTS
If you checked “NO” or “NEVER HAD ANY HOBBIES OR INTERESTS,” go to
Section D.
If “YES,” please LIST each hobby or interest and HOW OFTEN you do it.___________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________
b. Has there been any change in your ability to do any of the hobbies or interests you listed or
the time you spend on them because of your illnesses, injuries, or conditions?
YES NO
If “NO,” go to Section D.
If “YES,” please DESCRIBE the change. Pleases be SPECIFIC.
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SECTION D – OTHER INFORMATION
19. Answering this question is optional. Is there anyone you haven’t already told us about
(relative, friend, neighbor, former coworker, or boss) that we may contact (other than your doctors
or the person you named on your disability report) who knows about your illnesses, injuries, or
conditions?
Name ___________________________________ Relationship ______________________
Address __________________________________________________________________
(Number, Street, Apartment. Number (if any), P.O. Box or Rural Route
____________________________________________________________________________
City
State
Zip Code
Daytime Phone Number__________________
If you completed this form for yourself, go to Section E.
If you completed this form for the person applying for or receiving disability benefits, please
complete the information in question 20. When you are done with questions 20.a. and 20.b, go
to Section E.
20. a. What is your relationship to the disabled person (for example, spouse, neighbor, friend)?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Form SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)

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b. Please EXPLAIN why you are completing this form for the person applying for or
receiving disability benefits.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SECTION E - -REMARKS
Use this section for any added information you did not show in earlier parts of this form. When
you are done with this section (or if you don’t have anything to add), be sure to complete the
information requested on the bottom of page 14.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Form SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)

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____________________________________________________________________________
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_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

_______________________________________________________________________________
Name of person completing this form (Please Print)
Date
(month, day, year)
_______________________________________________________________________________
Address (Number and Street)
email address (optional)
_______________________________________________________________________________
City
State
Zip Code
_______________________________________________________________________________
Your daytime telephone number (Area code and number)
_______________________________________________________________________
Form SSA-3373-BK ( ) ef( ) DRAFT (4-05-06)

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