Addendum to Supporting Statement

Addendum 0635.doc

Function Report - Adult Third Party

Addendum to Supporting Statement

OMB: 0960-0635

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Addendum to Supporting Statement for Function Report – Adult Third Party

20 CFR 404.1512 and 20 CFR 416.912

Form SSA-3380-BK

OMB No. 0960-0635



Minor Revisions to the Collection Instrument


SSA is making the following revisions:


  • Change #1: We are revising the Privacy Act Statement on this form.


Justification #1: SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the form.

File Typeapplication/msword
File TitleAddendum to the Supporting Statement for Form SSA-3462
Author177717
Last Modified BySYSTEM
File Modified2018-07-25
File Created2018-07-25

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