The ssa has an optional form called the function report that dds uses when they are in need of additional information about how an applicant is able to function in. Jul 01, 2015 ssa will have an applicant complete the adult function report form ssa 3373 bk. These forms can be used for both adult ssissdi and child ssi applications. Have read that these forms are designed to disqualify you, more than help you receive approval. The social security administration will send you ssa3373, the function report, after you apply for benefits.
Typically, the process of applying for disability begins with you filing an initial claim for benefits and submitting a form ssa. How to fill out form ssa3369bk in san jose angelina. Socialsecuritynumber functionreportadult socialsecurityadministration formapproved ombno. Many forms must be completed only by a social security representative. Social security disability info disability answer guide. If you need the address or phone number for the office that provided the form, you can get it by calling social security at 180077212. 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. After reading thousands of pages of disability applications over the. The most secure digital platform to get legally binding. Fill function report adult form ssa3373bk social security ssa instantly, download blank or editable online. Some must be filled out at the beginning of the process, while others may be necessary down the road if your claim gets denied. Ssa 3373 bk pdf function report adult form ssa3373bk. Fu ctio reportadultformssa 3373 bk readallofthisiformatiobefore youbegicompletig thisform ifyoue edhelp ifyouneedhelpwiththisform. 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.
The social security administration is authorized to collect the information on this form under sections 205a and b, 223d and 1631e1 of the social security act. 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, 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. The disability determination services dds sends a claimant a function report form to complete at both the initial application and reconsideration stages. Fill online, printable, fillable, blank form ssa3373bk function report form. The dds will not send an ssa 827 when requesting a third party to complete the ssa 3380, unless the dds knows from past experience that the source requires it. The adult function report is used by the social security administration as part of the criteria used to determine whether an individual qualifies to receive disability. In order to be approved for social security disability benefits, it.
Comments and help with ssa 3369 bk fillable no no download needed needed. Social security forms social security administration. This form is critically important for explaining how your disability affects you. Form ssa 3368bk 102015 uf 102015 what we mean by disability disability under social security is based on your inability to work. Hearing preparation disability report appeal view and download form ssa3441bk. 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 ssa 3373 bk to complete. To determine this, the ssa needs a lot of information from you. It asks broad questions about your life and the response time to answer is short, usually 10 days. D103 post filing 3 what is a 3373 ssa disability form.
See form ssa3369 explanation page 47 in my disability answer guide. How to fill out form ssa3373 function report activities of daily living most applicants do not precisely meet a listed disability with the social security administration ssa. The ssa 3373 is not mandatory in all cases for example, listinglevel impairments. One way you provide this information is through form ssa3373bk. They included form ssa16f6, a 6page document consisting of 22 questions and form ssa3368bk, a 10page document asking for detailed information about robertas past work, the names and addresses of her physicians, and facts about her medical treatment.
Fill free fillable form ssa3373bk function report pdf form. Formssa3373bk92005 ef092005 page1 forssauseonly donotwriteinthisbox. Social security form ssa 3373 bk is a lengthy form that you fill out as a part of the process of applying for social security disability benefits. Use fill to complete blank online social security administration md pdf forms for free. Third party function report for ssd cases neil good. Dont allow third parties to fill them out because i have never seen a third. If your medical condition does not meet a listing, then the ssa will need more information from you, including how your disability affects your everyday life. Considerations when filling out the adult function report ssa3373bk as part of your social security disability application maine social security disability lawyer. Easily personalize the doc by outlined spaces completing. Nov 26, 2018 the social security administration ssa needs to determine both that your injuries or conditions are actively preventing you from working and that theyll continue to do so for some time. Filling out the adult disability report form ssa3373bk 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.
Download from disability benefits law center milwaukee. This form should be completed with as much detail as possible. There are a number of considerations that individuals should take into account when addressing this form. This is done by assessing the answers you provide the ssa with on form 3373. Ssa1696sup1 instructions for completing form ssa1696sup1. Social security administration ssa forms and resources soar.
Create form ssa 3373 bk in minutes using a fillable pdf editor. Sometimes social security reps refer to the form as the adl questionnaire, but officially the ssa calls this form the function report, ssa3373. Form ssa3373bk is used to report an adult individuals ability to function. This disability questionnaire is designed to gauge the severity of.
Sign the ready paper, download or send right from signnow. In order to be approved for social security disability benefits, it is crucial that you answer the questions on form 3373 properly. Do i need to submit forms ssa3373bk, ssa3380bk, and ssa. If you download, print and complete a paper form, please mail or take it to your local social security office or the office that requested it. Form ssa3373 bk is used to report an adult individuals ability to function. Considerations when filling out the adult function report. This is a function report for an adult that is completed by a thirdparty. Fillable form ssa3373bk free printable pdf sample formswift. We estimate that it will take about 61 minutes to read the instructions, gather the facts, and answer the. Download a free ssa3373bk fillable page 3 to make your document professional and perfect.
There is space to list five jobs on the application, which is also known as the adult disability report, but the ssa will need more information about your past work. Here are some examples of the types of questions that appear on the function report. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. The social security administration will send you ssa3373, the function report, after you apply for benefits it is also commonly referred to as the activities of daily living or adl questionnaire. Function report adult third party form ssa3380bk 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. Printable and fillable form ssa 3373 bk form ssa 3373 bk edit, fill, sign online handypdf fillable online bookadik function report form ssa 3373 bk fillable function report form ssa 3373 bk fillable this particular function report form ssa 3373 bk fillable download pdf start with introduction, brief session till. 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. I recently applied, in person, for ss disability not ssi for multiple sclerosis. Goldsmith is dedicated to serving our clients with a range of legal services including social security disability and long term disability cases. While it is prepared by you, and not a professional, it is an important form. Most used of these questionnaires is the function report ssa 3373. How to fill out an adult function report activities of. Ssa uses the answers to the adult function report as one tool out of many to assess the severity of an individuals i.
A ssd lawyer can assist you in properly filling it out. Fillable form ssa3380bk free printable pdf sample formswift. Edit, fill, sign, download form ssa 3373 bk online on. The dds will use them if they determine that function development is needed. The investigation conducted on the basis of information. Find other professionally designed templates in tidyform. The importance of the adl form to your disability case. Common social security administration forms for public use. Social security disability forms for download disability. How to fill out an activities of daily living questionnaire or adult function report form. Dec 15, 2016 what are the biggest mistakes made by disability claimants when completing social securitys forms. Nameofdisabledpersonfirst, middle initial, last sectionageneralinformation relatedssn numberholder how your illnesses, injuries, or conditions limit your activities 4.
What you need to know about this form for your social security disability case. 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. Download and create your own document with ssa 3373 bk fillable 311kb 10 pages for free. Whatsapp fill out and sign printable pdf template signnow. After reading thousands of pages of disability applications over the past 20 years, i can tell.
Disability report adult social security administration. This disability questionnaire is designed to gauge the severity of your condition and how it affects your daily life some questions are personal, such as your ability to use the bathroom. Download and create your own document with ssa3373bk fillable 311kb 10 pages for free. If you lack some space while answering some questions you can use a remarks section on the las page of the form. Wellnesschiemsee function report form ssa 3373 bk fillable function report form ssa 3373 bk fillable by simone schweitzer click here for free. Administration ssa requires claimants to address a number of forms. The form ssa3373bk function report form is 16 pages long and contains. Avoid this mistake when completing social securitys. What information should be provided in an ssa 3373 bk form.
What information should be provided in an ssa3373bk form. This disability questionnaire is designed to gauge the severity of your condition and how it affects your daily life. The thirdparty chosen to complete this extensive form cannot be a medical professional treating the applicant. One of the doctors is my primary physician and he is the key for disability determination. The information on this form is needed by social security to make a decision on your claim or case. Function report adult third party form ssa 3380bk 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. Edit, fill, sign, download form ssa3375bk online on. Download fillable form ssa3373bk in pdf the latest version applicable for 2020. Nov 05, 2015 if you need help with your pending disability application, please fill out a free claim evaluation at. It is also commonly referred to as the activities of daily living or adl questionnaire. Function report adult social security administration. Once completed you can sign your fillable form or send for signing. To receive benefits, you will be required to submit a number of social security disability forms.
The adult function report is used by the social security administration as part of the criteria used to determine whether an individual qualifies to receive disability payments. Download ssa3373bk fillable for free page 4 tidyform. I filled and sent out ssa454bk form to ssa about 7 weeks ago. Filling out a third party function report function report adult third party form ssa3380bk my suggestion is dont have anybody fill one out. If you need help with your pending disability application, please fill out a free claim evaluation at. An ssa 3373 bk form is not accompanied by other forms.
Start a free trial now to save yourself time and money. Considerations when filling out the adult function report ssa. Form ssa3373 is the function report or activities of daily living. Social security disability forms to receive benefits, you will be required to submit a number of social security disability forms. Form ssa3373bk download fillable pdf or fill online. How to fill out form ssa3373function report activities of daily living most applicants do not precisely meet a listed disability with the social security administration ssa. Hearing request claimants statement when request for hearing is filed and issue is disability view and download form ha4486. Form ssa3380bk is a form used by an individual seeking disability benefits from the social security administration. The ssa 3373 records information about a claimants ability to function and to perform the activities of daily living, in the circumstances listed in di 11005. The form you are looking for is not available online. In this form i listed the name of doctors whom i am seeing for my disability. Download ssa3373bk fillable for free page 3 tidyform. Download a free ssa3373bk fillable page 4 to make your document professional and perfect.
How to fill it out, how does social security use this form in your ssdi ssd or ssi case. Form ssa3373bk, function report adult is a form used to determine whether an individual was eligible for social security disability benefits. Trying to find out how best to answer these questions to increase my 1st time approval chances. Please call us at 180077212 tty 18003250778 monday through friday between 8 a.
Filling out the adult disability report form ssa3373bk. How to apply for benefits with the ssa3369bk form is a part of a social security disability claim, together with the ssa3369 form. Fill out the function report adult online and print it out for free. How to complete this form 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. Fill, sign and send anytime, anywhere, from any device with pdffiller. This form is used by individuals applying for social security benefits. It also goes by the adult disability report or the adult function report. Fill out, securely sign, print or email your ssa 3373 20152018 form instantly with signnow. Form ssa3373bk download fillable pdf or fill online function. Social security disability functional report ssa 3373. Typically, the process of applying for disability begins with you filing an initial claim for benefits and submitting a form ssa827 to release your.
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. Download your completed forms as pdfs, or email them directly to colleagues. The only exception might be for a person with seizures which may require a third party observation. Considerations when filling out the adult function report ssa3373bk as part of. What are the biggest mistakes made by disability claimants when completing social securitys forms. Here are the ssa forms, links, and other helpful resources you will need to. Neither the ssa 3373 nor the ssa 3380 is mandatory for use in all cases. 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.
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, complete as much of it as you can and call the phone number. Sometimes social security reps refer to the form as the adl questionnaire, but officially the ssa calls this form the function report, ssa 3373. Sep 04, 2017 do i need to submit forms ssa 3373 bk, ssa 3380bk, and ssa 3369bk or are they unnessary possibly harmful to case. An ssa3373bk form is not accompanied by other forms. Social security administration fill free fillable forms. How to answer questions on disability form ssa 3373 bk. Collection of most popular forms in a given sphere. Edit, fill, sign, download form ssa3373bk online on. If you overlook these five important words, you could lose your case. Whether you are applying for social security disability as a disabled worker, a disabled widow, a disabled adult child or for ssi as an adult, in addition to the ssa16bk or ssa8000bk, you also have to complete an ssa3368 to provide medical information, an ssa3369 to provide your work history, and an ssa827, which allows the social. Work history report view and download form ssa3369bk.