Information Collection

Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)

IC 9455 under ICR 201904-0960-016 · OMB 0960-0542.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0542 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3375-BK Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2) Form
Revised PA Statement.pdf Other-Revised Privacy Act Statement
SSA-3375-BK Function Report-Child Birth to 1st Birthday SSA-3375-BK - Revised.pdf Form
SSA-3376-BK Function Report-Child Age 1 to 3rd Birthday SSA-3376-BK - Revised.pdf Form
SSA-3377-BK Function Report-Child Age 3 to 6th Birthday SSA-3377-BK - Revised.pdf Form
SSA-3378-BK Function Report-Child Age 6 to 12th Birthday SSA-3378-BK - Revised.pdf Form
SSA-3379-BK Function Report-Child Age 12 to 18th Birthday SSA-3379-BK - Revised.pdf Form
SSA-3375-BK - Current.pdf Current SSA-3375 IC Document
SSA-3376-BK - Current.pdf Current SSA-3376 IC Document
SSA-3377-BK - Current.pdf Current SSA-3377 IC Document
SSA-3378-BK - Current.pdf Current SSA-3378 IC Document
SSA-3379-BK - Current.pdf Current SSA-3379 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)	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 416.924a (a) (2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3375-BK	Function Report-Child Birth to 1st Birthday	SSA-3375-BK - Revised.pdf	Yes	No	Fillable Printable
Form	SSA-3376-BK	Function Report-Child Age 1 to 3rd Birthday	SSA-3376-BK - Revised.pdf	Yes	No	Fillable Printable
Form	SSA-3377-BK	Function Report-Child Age 3 to 6th Birthday	SSA-3377-BK - Revised.pdf	Yes	No	Fillable Printable
Form	SSA-3378-BK	Function Report-Child Age 6 to 12th Birthday	SSA-3378-BK - Revised.pdf	Yes	No	Fillable Printable
Other-Revised Privacy Act Statement for Forms SSA-3375 - SSA-3379			Revised PA Statement.pdf	No		Printable Only
Form	SSA-3379-BK	Function Report-Child Age 12 to 18th Birthday	SSA-3379-BK - Revised.pdf	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: 579,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	579,000	47,000	532,000
Annual IC Time Burden (Hours)	193,000	15,667	177,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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