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⚠️ Notice: This information collection may be referencing outdated material.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-BK (2015 Mock-up)).pdf Form and Instruction
SSA-3373 Function Report - Adult SSA-3373-BK (2015 Mock-up)).pdf www.socialsecurity.gov 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

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 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-3373	Function Report -- Adult	SSA-3373-BK (2015 Mock-up)).pdf		No		Paper Only
Form and Instruction	SSA-3373	Function Report - Adult	SSA-3373-BK (2015 Mock-up)).pdf	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 %

	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

Title	Document	Date Uploaded
SSA-3373-BK Revised Privacy Act Statement	SSA-3373-BK Revised Privacy Act Statement.pdf	05/14/2015
SSA-3373-BK Current Version	SSA-3373-bk Current Version.pdf	05/14/2015

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