SSA Form SSA-3380-BK

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SSA Form SSA-3380-BK

Sometimes life is not going in the most favorable way, and people have to apply for federal disability benefits. The state authorities provide sufficient support for people with various disability categories. If that is your case, all you need to do is gather the necessary papers and follow the legal instructions and recommendations. Just like any other serious and significant step in a person’s life, it requires attention, preparation, and effort.

Among other documents, the Social Security Administration may ask you to complete the SSA Form 3380-BK, which is also called the Third Party Adult Function Report. The document is filled out not by the person who applies for disability but by their responsible contact, meaning a third party.

The form is used by the respective authorities to decide whether to provide disability benefits for a particular person or to extend them. You can use our form-building software to create, customize, and fill out this form.

Who Does Complete This Document?

This document is completed by third parties at the request of the Social Security Administration to understand if the person defined in the application form needs and deserves federal disability benefits.

The administration will not ask random people or people you know little to fill out this form. When you apply, you have to indicate three contacts of people closest to you, and it is them that the service representatives keep in contact with. It is important that your contacts obtain the necessary knowledge about your situation and respond in your favor.

By the way, it will be useful to say that you do not need to specify precisely three contacts. If you have only one close person, write down their details and add that you do not have any more reliable people in your life to assign them responsible. This measure would be sufficient; nobody will demand you indicate unfamiliar persons just to fill in something.

Who Can Become Your Contact Person?

You should give this document to people close to you who know about your illness and have seen how it affects your life. You need to trust these people and make sure they will not let you down.

For instance, there was a case when a young man let his girlfriend fill out the Third Party Report. Soon after submitting the documents, they parted, and the upset girl contacted the service and said that she had lied in the report. This is certainly an extraordinary situation, but it is better to think several times about who you can indicate.

You are not allowed to give this document to your doctor or healthcare provider to complete.

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Step-By-Step Guide to Filling Out the Form

It is worth mentioning that in the document itself, it is noted that none of the columns can be left blank. But this does not mean at all that you need to invent if you do not know what to answer. You can just write “I don’t know.” This answer will also count.

Provide Contact Information

Enter the name of the disabled person in item 1. Next, you should specify:

  • your name;
  • the degree of relationship with a disabled person (friend, colleague, neighbor, and so on);
  • date of filling out the form;
  • your contact phone number.

step 1 provide contact information - filling out a form ssa-3380-bk
Insert Details About Your Relationship

Write how much time you know each other and how often you spend time together. It is worth pointing out that you are helping the disabled person, if so.

step 2 insert details about your relationship - filling out a form ssa-3380-bk
Check the Living Conditions

Check the box where the person lives and with whom.

step 3 check the living conditions - filling out a form ssa-3380-bk
Write About Existing Restrictions in Doing Work

If you are aware of the situation, write how a person’s disability interferes with the performance of the duties. You can indicate if colleagues or strangers have to help or assist them or how much effort has to be put into performing certain tasks.

step 4 write about existing restrictions in doing work - filling out a form ssa-3380-bk
Describe the Applicant’s Daily Routine

You can mention what difficulties arise during the day, whether a person is mobile or not, whether he/she leaves the house, whether can perform ordinary tasks. It should show what restrictions have appeared for the disabled person.

step 5 describe the applicant's daily routine - filling out a form ssa-3380-bk
Describe the Applicant’s Attitude Towards People or Pets

If a disabled person cares about someone — their loved ones or about pets, you need to indicate this here, and it is highly desirable to provide explanations. Taking full care of the dog is not at all the same as opening the door for it once a day so that it runs out into the yard. The administration may make an unsatisfactory decision if it thinks that the applicant is quite capable of caring for himself and others.

step 6 describe the applicant's attitude towards people or pets - filling out a form ssa-3380-bk
Note the Differences Before and After Disability

It is a goodwill practice to show on certain examples how complicated a person’s life has become after disability and what restrictions have appeared in it.

step 7.1 note the differences before and after disability - filling out a form ssa-3380-bk
The form also requires the applicant to describe sleeping problems (if there are any) in a separate section.

step 7.2 note the differences before and after disability - filling out a form ssa-3380-bk
Testify On Personal Care and Meals

In these questions, you can specify in more detail the difficulties of a person in everyday life, if any.

First, they ask for your answers regarding personal care:

  • Can a person take care of themself;
  • Whether the disabled person needs reminders of any kind;
  • If the person is able to take their own medications.

step 8.1 testify on personal care and meals - filling out a form ssa-3380-bk
This one is a rather detailed point, and you may not know about all the moments, in which case it is better to write this way.

step 8.2 testify on personal care and meals - filling out a form ssa-3380-bk
Next comes an extensive question regarding nutrition and personal independence in this matter.

step 8.3 testify on personal care and meals - filling out a form ssa-3380-bk
List Difficulties Associated With Housework

The question is whether disability affects housework or gardening, and can it be done in principle.

Indicate if someone helps with the housework. For example, if an assistant comes to vacuum and generally clean the house (or another dwelling unit) because the person is not able to do it independently (and not because the claimer is lazy), you should indicate it in the application form.

step 9.1 list difficulties associated with housework - filling out a form ssa-3380-bk
step 9.2 list difficulties associated with housework - filling out a form ssa-3380-bk
Answer the Questions Related to Leisure

More detailed answers related to a person’s free time are required. You must show if they can do particular activities related to daily maintenance and routine on their own:

  • Leaving home and driving;

step 10.1 answer the questions related to leisure - filling out a form ssa-3380-bk

  • Do shopping;

step 10.2 answer the questions related to leisure - filling out a form ssa-3380-bk

  • Deal with bills, bank accounts, money;

step 10.3 answer the questions related to leisure - filling out a form ssa-3380-bk
step 10.4 answer the questions related to leisure - filling out a form ssa-3380-bk

  • Do favorite hobby;

step 10.5 answer the questions related to leisure - filling out a form ssa-3380-bk

  • Social activity in general;

step 10.6 answer the questions related to leisure - filling out a form ssa-3380-bk
step 10.7 answer the questions related to leisure - filling out a form ssa-3380-bk
Carefully approach the filling of these points. They overlap with each other in many ways. You should not have a testimony that contradicts each other. For example, you cannot say that the applicant loves going to church on Sundays but does not leave home.

It is important to show how life and activities have changed after being sick or injured. Point out what was easy before, but not at all now.

Describe the Claimer’s Abilities

This broad clause deals directly with disability.

First of all, it is worth noting with a tick what human abilities the disease has affected.

step 11.1 describe the claimer's abilities - filling out a form ssa-3380-bk
And explain with examples how it is shown in the picture below.

step 11.2 describe the claimer's abilities - filling out a form ssa-3380-bk
Give detailed answers about how quickly a person gets tired, how long they can hold attention, whether they can follow instructions. Remember that all submitted answers must reflect what you wrote earlier.

step 11.3 describe the claimer's abilities - filling out a form ssa-3380-bk
There are questions about relationships with other people at work or government officials.

Mention the psychological state of a person:

  • How the person deals with stress
  • How changes in routine affect the person
  • If there are specific fears or anxiety

You will also need to note which assistive devices the applicant is using, if so.

step 11.4 describe the claimer's abilities - filling out a form ssa-3380-bk
If you know about pills that a disabled person has to take, indicate it in the form as well. All medical prescriptions (and the effect they have) need to be documented.

step 11.5 describe the claimer's abilities - filling out a form ssa-3380-bk
Add Other Relevant Info

If you want to add something or run out of space in the paragraphs above, you can write it here. Add a reference in the paragraph and include anything you want in Section E.

step 12 add other relevant info - filling out a form ssa-3380-bk
Provide Your Details

At the end of the form, you must leave your details, including the address, and put the date of the document completion.

step 13 provide your details - filling out a form ssa-3380-bk