Private Sector

Function Report - Adult Third Party

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form SSA-3380 Private Sector Form and Instruction
SSA-3380 Function Report--Adult--Third Party ssa3380(revised).pdf Form and Instruction
ssa3380.pdf SSA-3380 -- Current Version IC Document

Information Collection (IC) Details

IC Title:	Private Sector	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-3380	Function Report--Adult--Third Party	ssa3380(revised).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: 527,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	527,000	27,000	500,000
Annual IC Time Burden (Hours)	535,783	27,450	508,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3380 -- Current Version	ssa3380.pdf	07/10/2012

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