Form SSA-3373-BK Instructions
The SSA-3373-BK is a ten-page form that should be completed as follows:
- Section A. General Information. Provide your basic personal and contact information;
- Section B. Information about Your Illnesses, Injuries, or Conditions. Enumerate all your illnesses, injuries, and conditions. Describe how they affect your ability to work;
- Section C. Information about Daily Activities. Describe how your condition affects your daily routine. If you need help with daily activities, specify the help you need.;
- Section D. Information about Abilities. Provide the information about your abilities and the medications you are taking;
- Section E. Remarks. Add any information you think important that does not seem to fit in previous sections. Make sure to provide as much details as possible.
The last part of the form requires your name, completion date, and full mailing address. Send or take the document to the office that requested it. You can specify the address by calling the SSA.
Tips for Filling out SSA-3373-BK
Look through the useful tips that may facilitate the filing process below:
- Read the whole form before completing it;
- Answer every question. Do not leave blank boxes. If your answer is "None" or "Don't know" indicate it anyway;
- Print or type your answers;
- Provide all the required explanations. If the space provided is not enough, continue in the "Remarks" section;
- When providing the explanations, concentrate on your disabilities rather than abilities;
- Try to be consistent and do not provide unrelated information;
- Be honest. The SSA will compare your answers to your medical records. Willful representation of false statements may result in fine or imprisonment;
- Double-check your answers;
- Your doctor or hospital are not allowed to complete the form;
- Make a copy of the completed form for your records.
SSA-3373-BK Related Forms
- SSA-3375-BK, Function Report - Child Birth to 1st Birthday. The form is used to provide the SSA with information about children's injuries or illness. The SSA uses this information to make a decision on the disability claim. The form is applicable for children before age 1;
- SSA-3376-BK, Function Report - Child age 1 to 3rd Birthday. The document is used to report disabilities of child age 1 to 3. Based on this information, the SSA makes the decision about the Social Security benefits request;
- SSA-3377-BK, Function Report - Child age 3 to 6th Birthday. The form is submitted on the behalf of a minor child age 3 to 6 to report injuries and illnesses. The SSA uses this information to determine a child's eligibility for disability benefits;
- SSA-3378-BK, Function Report - Child age 6 to 12th Birthday. The form is used to specify how the illnesses and injuries children have affected their everyday life. This report is the basis of the SSA decision on a child's disability claim;
- SSA-3379-BK, Function Report - Child age 12 to 18th Birthday. The SSA uses the form to determine if the child is eligible for disability benefits. The document should contain detailed information on how disabilities affect the everyday life of a child age 12 to 18;
- SSA-3380-BK, Function Report - Adult - Third Party Form. The form is used to make a decision on an application for disability benefits. The form should provide all requested information.