Information Collection

Function Report - Adult

IC 9735 under ICR 201505-0960-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Function Report -- Adult Function Report - Adult	Form and Instruction
Form SSA-3373 Function Report - Adult Function Report - Adult	Form and Instruction
SSA-3373 Function Report -- Adult SSA-3373-BK (2015 Mock-up)).pdf	Form and Instruction
SSA-3373 Function Report - Adult SSA-3373-BK (2015 Mock-up)).pdf	Form and Instruction
SSA-3373-BK Revised Privacy Act Statement.pdf SSA-3373-BK Revised Privacy Act Statement	IC Document
SSA-3373-bk Current Version.pdf SSA-3373-BK Current Version	IC Document

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 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-3373				No		Paper Only
Form and Instruction	SSA-3373			www.socialsecurity.gov	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,085,721

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	2,085,721	-2,135,935	4,221,656
Annual IC Time Burden (Hours)	2,120,483	-2,171,534	4,292,017
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3373-BK Revised Privacy Act Statement		05/14/2015
SSA-3373-BK Current Version		05/14/2015

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

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