SSA-3380

Function Report - Adult - Third Party Form

Download and Print the SSA-3380

Request may not be processed if the form is incomplete or illegible.

1. NAME OF DISABLED PERSON (First, Middle, Last)

2. YOUR NAME (Person completing the form)

3. RELATIONSHIP (To disabled person)

4 . DATE (Month, Day, Year)

5. YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached, please give us a daytime number where we can leave a message for you.)

( ) Area Code - - Phone Number
Your Number
Message Number
None

6. a. How long have you known the disabled person?

     b. How much time do you spend with the disabled person and what do you do together?

7. a. Where does the disabled person live? (Check one.) House - Apartment - Boarding House
Nursing Home - Shelter - Group Home - Other - (What?)

    b. With whom does he/she live? (Check one.)
Alone - With Family - With Friends - Other

(Describe relationship.)

SECTION B - INFORMATION ABOUT ILLNESSES, INJURIES, OR CONDITIONS

8. How do this person's illnesses, injuries, or conditions limit his/her ability to work?

And much more...