Function Report - Adult Third Party

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0635 can be found here:

Documents and Forms

Document Name Document Type
Privacy Act Statement (revised).doc Other-Privacy Act Statement Revised
PRA (revised).doc Other-PRA (revised)
SSA-3380 Function Report -- Adult Third Party SSA-3380 (revised).pdf Form and Instruction
ssa-3380(current).pdf SSA-3380 -- Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Function Report - Adult Third Party	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-PRA (revised)			PRA (revised).doc	No		Paper Only
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 (revised).doc	No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 78,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	78,000	-449,000	527,000
Annual IC Time Burden (Hours)	79,300	-456,483	535,783
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3380 -- Current Version	ssa-3380(current).pdf	05/14/2015

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