We will use the information you provide on behalf of the minor child to determine his or her benefit eligibility. This form is usually sent out two or three months after you first apply. Fill free fillable form ssa3373bk function report pdf form. A form ssa 3373bk is known as an adult function report. Social security form ssa3373bk is a lengthy form that you fill out as a part of the process of applying for social security disability benefits. Then call the phone number provided on the letter sent with the form or the phone number of the person who asked you to complete the form for help to finish it. Form ssa3373bk download fillable pdf or fill online. How to fill it out, how does social security use this form in your ssdi ssd or ssi case. 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.
Ssa will have an applicant complete the adult function report form ssa 3373bk. Function report adult social security administration. The form you are looking for is not available online. Edit, fill, sign, download form ssa3373bk online on.
Ssa3378bk 102017 uf discontinue prior editions social security administration. The ssa needs to determine whether or not the effects of your diagnosed condition have led to an inability to work. Social security form 3373bk is also called a function report, and helps the ssa understand the condition you are using to apply for social security disability benefits. Do i need to submit forms ssa3373bk, ssa3380bk, and. Filling out the adult disability report form ssa3373bk. The function report ssa 3373 helps dds to obtain information about how an applicants illnesses and conditions affect their ability to function and perform everyday tasks. An ssa3373bk form is not accompanied by other forms. Fill out the function report adult online and print it out for free. Here are the ssa forms, links, and other helpful resources you will need to complete ssi andor ssdi applications. Social security attorneys and medical professionals refer to this as an adl questionnaire activities of daily living. Form ssa3377 bk 102017 uf sections 205a, 223d, and 1631e1, of the social security act, as amended, authorize us to collect this information. Considerations when filling out the adult function report. Social security forms social security administration.
How to fill out an activities of daily living questionnaire or adult function report form. Formssa 3373 bk 122009 ef042010 destroyprioreditions page1 forssauseonly donotwriteinthisbox. An ssa 3373 bk form is not accompanied by other forms. Function report adult form ssa 3373 bk the information that you give us on this form will be used by the office that makes the disability decision on your disability claim. How to fill out an adult function report third party form. Tips in completing the adult function report ssa 3373bk edit.
Whatsapp fill out and sign printable pdf template signnow. Click here for further instructions on navigating and completing some of the. Form ssa4734bk 082008 ef 082008 formerly ssa4734u8 use prior editions page 1 insured. Work history report social security administration. Form ssa3378bk 62003 ef 022005 continued on the reverse destroy prior editions please remove this sheet before returning the completed form. Edit, fill, sign, download form ssa3375bk online on. In ssa s assessment of a claimants past work, ssa will require a claimant to complete a work history report form ssa 3369 bk. Third party adult function report is a form that social security sometimes send to your contact person. Social security administration ssa forms and resources. It is quite common to see that at the initial filing level, at the reconsideration level, or both, the claimant will be sent along an adult function report ssa3373bk to complete.
It is also commonly referred to as the activities of daily living or adl. Use fill to complete blank online social security administration md pdf forms for free. The information requested on this form is authorized by section 223 and section 1633 of the social security act. Download and create your own document with ssa3373bk fillable 311kb 10 pages for free. Tips in completing the adult function report ssa 3373bk jun 17. Fu ctio reportadultformssa3373bk readallofthisiformatiobefore youbegicompletig thisform ifyoue edhelp. You can help them by completing as much of the form as you can. If you lack some space while answering some questions you can use a remarks section on the las page of the form. Edit, fill, sign, download form ssa 3373bk online on. Do i need to submit forms ssa3373bk, ssa3380bk, and ssa3369bk or are they unnessary possibly harmful to case. Anybody know if this is a 8 page standard form everybody has to fill out or what i would have thought it would have been part of the initial application andor part of the inperson interview.
Trying to find out how best to answer these questions to increase my 1st time approval chances. How to complete a social security disability application. What you need to know about this form for your social security disability case. For purposes of this claim, we want you to understand that disability means you are unable to work as defined by the social security act.
After you have made a social security disability claim and have had your initial interview, you may be asked to fill out form 3373bk, the adult disability report. You can apply online, on paper, in person, on the phone or through a lawyer. This form will be used by the social security administration to determine whether or not someone is eligible for social security. Fill online, printable, fillable, blank form ssa3373bk function report form. The most secure digital platform to get legally binding, electronically signed. Fill out, securely sign, print or email your ssa 3373 20152018 form instantly with signnow. Under the social security act, the social security administration. The social security administration will send you ssa3373, the function report, after you apply for benefits. As part of ssas disability determination process, ssa will evaluate the severity of an individuals claimant. How to fill out forms and answer questions for social. This form will be used by the social security administration to determine whether or not someone is eligible for social security benefits such as disability or ssi.
Social security disability functional report ssa 3373. Work history report form ssa3369 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. Form ssa3368 bk 102015 uf 102015 what we mean by disability disability under social security is based on your inability to work. The work history report is very important to the disability determination process and the claimant should take care and time in completing the form. Wellnesschiemsee function report form ssa 3373 bk fillable function report form ssa 3373 bk fillable by simone schweitzer click here for free. Function report adult form ssa3373bk read all of this information before you begin completing this form if you need help if you need help with this form.
Many forms must be completed only by a social security representative. Form ssa3373bk download fillable pdf or fill online function. Form ssa3373bk 122009 ef 042010 destroy prior editions. The information we ask for on this form tells us how you think the childs illnesses or injuries affect the way he or she does many of his or her usual activities.
Fu ctio reportadultformssa 3373 bk readallofthisiformatiobefore youbegicompletig thisform ifyoue edhelp. Please call us at 180077212 tty 18003250778 monday through friday between 8 a. I recently applied, in person, for ss disability not. The ssa3373 records information about a claimants ability to function and to perform. What information should be provided in an ssa 3373 bk form. Disability report adult social security administration.
Tips in completing the work history report ssa 3369 bk. This is a lengthy form that is required in order for the ssa to examine how well an individual can function during the. Function report adult form ssa3373bk the information that you give us on this form will be used by the office that makes the disability decision on your disability claim. Ssa3373 function report social security disability. How to fill out an adult function report activities of. Since the date on page 1, have you or your spouse living with you had any change in health insurance coverage or other insurance that. This is a function report for an adult that is completed by a thirdparty. It is important that you tell us about your activities and abilities. Download fillable form ssa3373bk in pdf the latest version applicable for 2020.
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