Information Collection

Function Report - Adult

IC 9735 under ICR 202609-0960-004 · OMB 0960-0681.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3373 Function Report -- Adult Function Report - Adult	Form and Instruction
Form SSA-3373 Function Report -- Adult Function Report - Adult	Form and Instruction
Privacy Act Statement - Revised.docx	Other-Revised PA Statement
SSA-3373 Function Report -- Adult SSA-3373 - Revised (Marked-Up Version).pdf	Form and Instruction
SSA-3373 Function Report -- Adult Upload-Documents-Screenshots - 0681 (SSA-3373) 2026-04.docx	Form and Instruction
SSA-3373-bk-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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3373	No		Paper Only
Form and Instruction	SSA-3373	Yes	Yes	Fillable Fileable
Other-Revised PA Statement		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,812,929

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,812,929	78,294	1,734,635
Annual IC Time Burden (Hours)	3,233,057	602,194	2,630,863
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3373-Current		09/09/2026

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

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