Function Report - Adult

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form SSA-3373 Function Report - Adult Form and Instruction
SSA-3373 Function Report -- Adult SSA-3373 Revised Version.pdf Form and Instruction
ssa3373 Current Version.pdf SSa-3373 -- Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3373	Function Report -- Adult	SSA-3373 Revised Version.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: 4,221,656	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,221,656	216,289	4,005,367
Annual IC Time Burden (Hours)	4,292,017	219,894	4,072,123
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSa-3373 -- Current Version	ssa3373 Current Version.pdf	07/30/2012

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