Information Collection

Function Report - Adult Third Party

IC 9663 under ICR 202110-0960-003 · OMB 0960-0635.

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 0635 (revised).docx	Other-Privacy Act Statement Revised
PRA 0635 (revised).docx	Other-Paperworkd Reduction Act (revi
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:

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 404.1512 20 CFR 416.912

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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 0635 (revised).docx	No		Paper Only
Other-Paperworkd Reduction Act (revised)			PRA 0635 (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
	Requested	Previously Approved
Annual Number of Responses for this IC	709,700	709,700
Annual IC Time Burden (Hours)	721,528	721,528
Annual IC Cost Burden (Dollars)	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.