Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Paper Forms

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)

Documents and Forms

Document Name Document Type
Form SSA-3375 Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Paper Forms Form
Revised PA Statement.pdf Other-Revised Privacy Act Statement
SSA-3375 Function Report - Child Birth to 1st Birthday SSA-3375-BK - Revised.pdf www.ssa.gov Form
SSA-3376-BK Function Report - Child Age 1 to 3rd Birthday SSA-3376-BK - Revised.pdf www.ssa.gov Form
SSA-3377-BK Function Report - Child Age 3 to 6th Birthday SSA-3377-BK - Revised.pdf www.ssa.gov Form
SSA-3378-BK Function Report - Child Age 6 to 12th Birthday SSA-3378-BK - Revised.pdf www.ssa.gov Form
SSA-3379-BK Function Report - Child Age 12 to 18th Birthday SSA-3379-BK - Revised.pdf www.ssa.gov Form
SSA-3375-BK - Current.pdf SSA-3375-BK - Current Version IC Document
SSA-3376-BK - Current.pdf SSA-3376-BK - Current Version IC Document
SSA-3377-BK - Current.pdf SSA-3377-BK - Current Version IC Document
SSA-3378-BK - Current.pdf SSA-3378-BK - Current Version IC Document
SSA-3379-BK - Current.pdf SSA-3379-BK - Current Version IC Document

Information Collection (IC) Details

IC Title:	Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Paper Forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	URL	Available Electronically?	Electronic Capability
Form	SSA-3375	Function Report - Child Birth to 1st Birthday	SSA-3375-BK - Revised.pdf	www.ssa.gov	No	Fillable Printable
Form	SSA-3376-BK	Function Report - Child Age 1 to 3rd Birthday	SSA-3376-BK - Revised.pdf	www.ssa.gov	No	Fillable Printable
Form	SSA-3377-BK	Function Report - Child Age 3 to 6th Birthday	SSA-3377-BK - Revised.pdf	www.ssa.gov	No	Fillable Printable
Form	SSA-3378-BK	Function Report - Child Age 6 to 12th Birthday	SSA-3378-BK - Revised.pdf	www.ssa.gov	No	Fillable Printable
Form	SSA-3379-BK	Function Report - Child Age 12 to 18th Birthday	SSA-3379-BK - Revised.pdf	www.ssa.gov	No	Fillable Printable
Other-Revised Privacy Act Statement			Revised PA Statement.pdf		No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 57,900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-57,900	57,900
Annual IC Time Burden (Hours)	-48,250	48,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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