SSA-3375
Function Report - Child To 1st Birthday
Download and Print
the SSA-3375
Request may not be processed if the form is incomplete or illegible.
Filling Out The Function Report
IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, CONTACT YOUR SOCIAL SECURITY OFFICE. 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 the child's claim. You can help them by completing as much of the form as you can.
Print or type.
Do not ask a doctor or hospital to complete this form.
Be sure to explain your answer if an explanation is requested or needed.
If more space is needed to answer any of the questions, please use the "REMARKS" section and show the number of the question being answered.
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
And much more...
|
