Information Collection

Function Report - Adult

IC 9735 under ICR 202104-0960-006 · OMB 0960-0681.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3373 Function Report - Adult	Form and Instruction
Form SSA-3373 Function Report -- Adult Function Report - Adult	Form and Instruction
Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
SSA-3373 Function Report -- Adult SSA-3373 - Revised.pdf	Form and Instruction
SSA-3373 Function Report -- Adult SSA-3373 - Revised (Marked-Up Version).pdf	Form and Instruction
SSA-3373 - Current.pdf SSA-3373 - Current	IC Document
SSA-3373 - Current.pdf SSA-3373 - Current	IC Document

IC Title:

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-3373				No		Paper Only
Other-Revised PA and PRA Statements					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
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,734,635	0	1,734,635
Annual IC Time Burden (Hours)	2,630,863	867,317	1,763,546
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3373 - Current		07/14/2021

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

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