Function Report Child - Child Age 1 to 3rd Birthday - SSA-3376

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-3376-BK Function Report Child - Child Age 1 to 3rd Birthday - SSA-3376 Form and Instruction
SSA-3376-BK Function Report Child - Child Age 1 to 3rd Birthday SSA-3376-BK.pdf www.ssa.gov Form and Instruction

Information Collection (IC) Details

IC Title:	Function Report Child - Child Age 1 to 3rd Birthday - SSA-3376	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.924a(a)(2) 20 CFR 416.912

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3376-BK	Function Report Child - Child Age 1 to 3rd Birthday	SSA-3376-BK.pdf	www.ssa.gov	Yes	No	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53,347	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
Annual Number of Responses for this IC	53,347	53,347
Annual IC Time Burden (Hours)	80,910	80,910
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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