Printable Ssa 3373 Bk Form All forms are FREE Not all forms are listed If you can t find the form you need or you need help completing a form please call us at 1 800 772 1213 TTY 1 800 325 0778 or contact your local Social Security office and we will help you
The information that you give us on this form will be used by the office that makes the disability decision on your disability claim You can help them by completing as much of the form as you can It is important that you tell us about your activities and abilities Print or type DO NOT LEAVE ANSWERS BLANK The information we ask for on this form tells us how you think the child s illnesses or injuries affect the way he or she does many of his or her usual activities PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM Continued on the Reverse Form SSA 3377 BK 02 2022 UF Page 2 of 10 Privacy Act Statement
Printable Ssa 3373 Bk Form
Printable Ssa 3373 Bk Form
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A Policy Use the SSA 3373 to collect information about a claimant s ability to function and to perform the activities of daily living The information detailed on the SSA 3373 may be obtained by telephone and recorded on an SSA 5002 in lieu of using the SSA 3373 Supplemental information may be added to the SSA 3373 What Is Form SSA 3373 BK Form SSA 3373 BK is a lengthy form that you fill out as a part of the process of applying for Social Security Disability benefits It also goes by the Adult Disability Report or the Adult Function Report
FUNCTION REPORT ADULT Form Approved OMB No 0960 0681 How your illnesses injuries or conditions limit your activities For SSA Use Only Do not write in this box Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act or knowingly conceals The Social Security Administration is authorized to collect the information on this form under sections 205 a and b 223 d and 1631 e 1 of the Social Security Act The information on this form is needed by Social Security to make a decision on your claim or case
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The information that you give on this form will be used to make a decision on the disabled person s claim You can help by completing as much of the form as you can When a question refers to the disabled person it refers to the person who is applying for or receiving disability benefits Form SSA 3373 BK is used to report an adult individual s ability to function The Adult Function Report is used by the Social Security Administration as part of the criteria used to determine whether an individual qualifies to receive disability payments This form should be completed with as much detail as possible
If you need the address or phone number for the office that provided the form you can get it by calling Social Security at 1 800 772 1213 HOW TO COMPLETE THIS FORM The information that you give us on this form will be used by the office that makes the disability decision on your disability claim You can help them by completing as much of To facilitate statistical research audit or investigative activities necessary to assure the integrity and improvement of Social Security programs e g to the Bureau of the Census and private concerns under contract to Social Security We may also use the information you provide in computer matching programs
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All forms are FREE Not all forms are listed If you can t find the form you need or you need help completing a form please call us at 1 800 772 1213 TTY 1 800 325 0778 or contact your local Social Security office and we will help you
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The information that you give us on this form will be used by the office that makes the disability decision on your disability claim You can help them by completing as much of the form as you can It is important that you tell us about your activities and abilities Print or type DO NOT LEAVE ANSWERS BLANK
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Printable Ssa 3373 Bk Form - The information that you give us on this form will be used by the office that makes the disability decision on your disability claim You can help them by completing as much of the form as you can It is important that you tell us about your activities and abilities Print or type DO NOT LEAVE ANSWERS BLANK
