Information Collection

Function Report - Adult Third Party

IC 9663 under ICR 201805-0960-013 · OMB 0960-0635.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3380 Function Report - Adult Third Party	Form and Instruction
Privacy Act Statement (revised).docx	Other-Privacy Act Statement Revised
SSA-3380 Function Report -- Adult Third Party ssa-3380 (revised).pdf	Form and Instruction
ssa-3380 (current).pdf SSA-3380 -- Current Version	IC Document

IC Title:

Function Report - Adult Third Party

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-3380	Function Report -- Adult Third Party	ssa-3380 (revised).pdf		Yes	No	Fillable Printable
Other-Privacy Act Statement Revised			Privacy Act Statement (revised).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 709,700

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	709,700	631,700	78,000
Annual IC Time Burden (Hours)	721,528	642,228	79,300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3380 -- Current Version	ssa-3380 (current).pdf	07/25/2018

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