Information Collection

0960-0681 - Function Report-Adult

IC 234811 under ICR 201901-0960-009 · OMB 0960-0813.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0813 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3373 0960-0681 - Function Report-Adult	Form
SSA-3373 Function Report - Adult SSA-3373 - Revised Version.pdf	Form
Supporting Statement - 0681 (for RIN 0960-AH86).docx Supporting Statement - 0681 (for RIN 0960-AH86)	IC Document
Addendum - 0681 (for RIN 0960 AH86).docx Addendum - 0681 (for RIN 0960 AH86)	IC Document
SSA-3373 - Current Version.pdf SSA-3373 - Current Version	IC Document

IC Title:

0960-0681 - Function Report-Adult

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	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: 1,734,635

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,734,635	1,734,635
Annual IC Time Burden (Hours)	1,763,546	1,763,546
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement - 0681 (for RIN 0960-AH86)	Supporting Statement - 0681 (for RIN 0960-AH86).docx	02/01/2019
Addendum - 0681 (for RIN 0960 AH86)	Addendum - 0681 (for RIN 0960 AH86).docx	01/31/2019
SSA-3373 - Current Version	SSA-3373 - Current Version.pdf	01/31/2019

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