Information Collection

Function Report - Adult Third Party

IC 9663 under ICR 201805-0960-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Function Report - Adult Third Party Form and Instruction
Privacy Act Statement (revised).docx Other-Privacy Act Statement 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 416.912 20 CFR 404.1512

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	Function Report -- Adult Third Party	ssa-3380 (revised).pdf		Yes	No	Fillable Printable
Other-Privacy Act Statement Revised			Privacy Act Statement (revised).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 709,700	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	709,700	631,700	78,000
Annual IC Time Burden (Hours)	721,528	642,228	79,300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3380 -- Current Version	ssa-3380 (current).pdf	07/25/2018

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