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Get Social Security Third Party Form 2020-2024

How do this person s illnesses injuries or conditions limit his/her ability to work Form SSA-3380-BK 12-2009 ef 01-2013 Use 12-2009 Edition Until Supply Exhausted Page 1 9. FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM IF YOU NEED HELP HOW TO COMPLETE THIS FORM 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. If you need more space to answer any questions use the REMARKS section on Page 8 and show the number of the question being answered. REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON COMPLETING THIS FORM ON PAGE 8 Function Report - Adult - Third Party Form SSA-3380-BK If you need help with this form complete as much of it as you can and call the phone number provided on the letter sent with the form or contact the person who asked you to complete the form. 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 TTY 1-800-325-0778. It is important that you tell us what you know about the disabled person s activities and abilities. DO NOT ASK THE DISABLED PERSON TO GIVE YOU ANSWERS Print or type. DO NOT LEAVE ANSWERS BLANK. If you do not know the answer or the answer is none or does not apply please write don t know or none or does not apply. Do not ask a doctor or hospital to complete this form* Be sure to explain an answer if the question asks for an explanation or if you think you need to explain an answer. Privacy Act and Paperwork Reduction Act Statements Sections 205 a 1631 d 1 and 1631 e 1 of the Social Security Act as amended authorize us to collect this information* We will use this information to process the named claimant s claim* Furnishing us the information is voluntary. However failing to provide us with all or part of the requested information may prevent us from making an accurate and timely decision on the named claimant s claim* We rarely use this information for any purpose other than for making a decision regarding entitlements to benefits. However we may use it for the administration and integrity of Social Security programs. We may also disclose information to another agency in accordance with approved routine uses which include but are not limited to the following 1. To enable a third party or agency to assist Social Security in establishing rights to Social Security benefits and/or coverage 2. To comply with Federal laws requiring the release of information from our records e*g* to the Government Accountability Office and the Department of Veterans Affairs 3. To make determinations for eligibility in similar health and income maintenance programs at the Federal State and local level and 4. To facilitate statistical research audit or investigatory activities necessary to assure the integrity and improvement of Social Security programs.

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