Function Report - Adult

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0681 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3373 Function Report - Adult Form and Instruction
SSA-3373 Function Report -- Adult SSA-3373 Revised Version.pdf Form and Instruction
SSA-3373 Function Report - Adult SSA-3373 - Fillable PDF Version.pdf www.socialsecurity.gov Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Function Report - Adult	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3373	Function Report -- Adult	SSA-3373 Revised Version.pdf		No		Paper Only
Form and Instruction	SSA-3373	Function Report - Adult	SSA-3373 - Fillable PDF Version.pdf	www.socialsecurity.gov	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,221,656	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	4,221,656	4,221,656
Annual IC Time Burden (Hours)	4,292,017	4,292,017
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.