Information Collection

Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912

IC 9663 under ICR 200608-0960-004 · OMB 0960-0635.

⚠️ Notice: This information collection may be referencing outdated material.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
Form SSA-3380-BK Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912 Form and Instruction
SSA-3380-BK Function Report--Adult--Third Party SSA-3380-BK.pdf Form and Instruction
SSA-3380-BK Function Report--Adult--Third Party (Revised Version) 3380.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912	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-3380-BK	Function Report--Adult--Third Party	SSA-3380-BK.pdf		No		Paper Only
Form and Instruction	SSA-3380-BK	Function Report--Adult--Third Party (Revised Version)	3380.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,000,000	0	0	1,000,000
Annual IC Time Burden (Hours)	1,000,000	250,000	250,000	500,000
Annual IC Cost Burden (Dollars)	0	0	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.