Function Report – Adult – Third Party (Form SSA-3380-BK) Completed Form Examples and Samples
View a detailed sample of a filled-out Function Report – Adult – Third Party (Form SSA-3380-BK). This example shows how to effectively describe an applicant's daily limitations, helping you understand how to complete this crucial Social Security disability form.
Function Report – Adult – Third Party (Form SSA-3380-BK) Example
How this form was filled:
This is an example of a completed SSA-3380-BK form filled out by a spouse for an applicant suffering from severe anxiety, depression, and chronic back pain. It details how these conditions impact daily activities, social interactions, and physical capabilities.
Information used to fill out the document:
- Applicant's Name: Sarah Jenkins
- Applicant's Social Security Number: 987-65-4321
- Third Party's Name: Mark Jenkins
- Relationship to Applicant: Husband
- Third Party's Phone Number: (555) 123-4567
- Applicant's Conditions: Major Depressive Disorder, Generalized Anxiety Disorder, Degenerative Disc Disease
- Date of Form Completion: January 15, 2026
- Impact on Daily Life: Needs help with personal care, meal preparation, and all household chores. Rarely leaves the house.
- Physical Limitations: Cannot lift more than 10 lbs; can only sit or stand for 15-20 minutes at a time due to back pain.
- Mental Limitations: Poor concentration, memory loss, lack of motivation, and panic attacks in social situations.
- Social Functioning: Avoids all social contact with friends and family; husband does all shopping and errands.
- Hobbies/Interests: Has lost interest in previous hobbies like gardening and reading; mostly watches TV.
What this filled form sample shows:
- Provides detailed descriptions of how mental health conditions (anxiety, depression) affect daily routines and motivation.
- Includes specific examples of physical limitations, such as weight that can be lifted and duration of sitting/standing.
- Clearly establishes the third party's close relationship and extensive knowledge of the applicant's daily struggles.
- Demonstrates how to connect the diagnosed illnesses to concrete functional limitations in a clear and consistent manner.
- Shows how to fill out sections on memory, concentration, and social interaction to reflect cognitive and emotional difficulties.
Form specifications and details:
| Form Name: | Function Report – Adult – Third Party (Form SSA-3380-BK) |
| Use Case: | Spouse reporting for an applicant with combined mental and physical impairments. |
| Focus: | Demonstrating limitations in daily living, social functioning, and concentration due to depression, anxiety, and chronic pain. |
Created: February 10, 2026 11:26 PM
