Form Ssa 3373 Bk Fillable 2020

With whom do you live Check one. Alone With Family With Friends Other Describe relationship. SECTION B - INFORMATION ABOUT DAILY ACTIVITIES Describe what you do from the time you wake up until going to bed. Form SSA-3373-BK 6-2004 ef 07-2004 Page 1 7. FUNCTION REPORT - ADULT - Form SSA-3373-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM IF YOU NEED HELP 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. If more space is needed 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 - Form SSA-3373-BK HOW TO COMPLETE THIS FORM Privacy Act and Paperwork Reduction Act Statements The Social Security Administration is authorized to collect the information on this form under sections 205 a 1631 d 1 and 1631 e 1 of the Social Security Act. 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. 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. The information on this form is needed by Social Security to make a decision on the named claimant s claim* While giving us the information on this form is voluntary failure to provide all or part of the requested information could prevent an accurate or timely decision on the name claimant s claim* Although the information you furnish is almost never used for any purpose other than making a determination about the claimant s disability such information may be disclosed by the Social Security Administration as follows 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 Social Security records e*g* to the General Accounting Office and the Department of Veterans Affairs and 3 to facilitate statistical research and such activities necessary to assure the integrity and improvement of the 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 give us when we match records by computer. Matching programs compare our records with those of other Federal State or local government agencies.