How to Fill Out Form SSA-3377-BK (w/Examples) + FAQs

Form SSA-3377-BK is the Social Security Administration’s Function Report – Adult – Third Party, and you fill it out by giving honest, detailed, day-by-day descriptions of how a disability limits the claimant’s ability to function. The form asks a third party — usually a spouse, parent, friend, or caregiver — to describe the claimant’s daily activities, physical abilities, mental abilities, and social interactions so the Disability Determination Services (DDS) can decide if the person qualifies for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).

The legal authority behind this form comes from 20 C.F.R. § 404.1513, which lets SSA accept evidence from non-medical sources, and from SSR 16-3p, which guides how SSA weighs symptom statements. If the form is vague, late, or inconsistent with medical records, the claim can be denied at the initial level, which is why nearly two-thirds of initial disability claims are denied every year.

Here is what you will learn from this guide:

📋 How to complete every line on Form SSA-3377-BK with confidence
⚖️ Which federal rules and rulings shape how SSA reads your answers
🧠 How to describe both physical and mental limits in plain language
⚠️ Which mistakes sink third-party reports and how to avoid them
✅ Real examples, do’s and don’ts, and FAQs that solve common problems

What Form SSA-3377-BK Is and Why It Matters

Form SSA-3377-BK is a 10-page questionnaire that SSA mails to a person who knows the claimant well. It is the third-party companion to the claimant’s own Form SSA-3373-BK, the Function Report – Adult. The two forms are designed to be compared, so any large gap between them can hurt the claim.

The form is a key piece of non-medical evidence. Under 20 C.F.R. § 404.1502, non-medical sources include family, friends, neighbors, employers, and clergy. The plain-English meaning is that SSA wants to hear from people who see the claimant every day, not just doctors. The consequence of skipping or rushing this form is that DDS may assume the claimant has fewer limits than they really have. A real-world example: Maria, a daughter caring for her mother with rheumatoid arthritis, returned the form with one-word answers, and her mother’s claim was denied at step four because DDS could not see how the disease limited daily life. A common misconception is that doctors’ notes alone decide the case, but the POMS DI 22505.001 instructs DDS to weigh function reports alongside medical records.

The form matters most during the initial application, reconsideration, and continuing disability reviews (CDRs). SSA uses POMS DI 22510.005 to develop function evidence at each of those stages. The consequence of treating the form as a formality is a longer appeal road that, according to SSA’s appeals data, often runs more than a year. A common misconception is that you need legal training to fill it out, but plain, specific, truthful answers carry more weight than legal language.

Who Should Fill It Out

The third-party reporter should be someone who has seen the claimant in daily life for a long stretch. SSA prefers a spouse, parent, adult child, sibling, close friend, roommate, or caregiver. Coworkers and former employers can also serve, especially if the disability shows up at work. Under 20 C.F.R. § 404.1513(a)(4), these statements are accepted evidence.

Pick the person who sees the worst days, not only the good days. The consequence of choosing a distant relative who only visits on holidays is a thin report that DDS cannot rely on. For example, David, a neighbor who only saw the claimant at church, knew less than the claimant’s live-in brother and produced a weaker report. A common misconception is that a paid caregiver’s report counts less than a family member’s, but SSR 06-03p and its successor guidance allow strong weight when the source has frequent contact.

When You Must Return It

SSA usually gives a return deadline of 10 days on the cover letter. The plain-English rule is to mail or upload it fast. The consequence of missing the deadline is that DDS can decide the case without your input, which often leads to a denial. A real-world example: Janet mailed her brother’s form two weeks late, and DDS had already issued an initial denial. A common misconception is that you can wait until the appeal, but appeal-stage reports rarely undo a flawed initial record.

Section-by-Section Walkthrough of SSA-3377-BK

The form has eight major parts. Each part should be answered with specifics, not generalities. SSA examiners are trained by POMS DI 22510.006 to look for vague language and treat it as weak evidence.

Section A: General Information

This first section asks for your name, address, daytime phone, your relationship to the claimant, and how often and how long you spend time with the claimant. Be exact. Write “I am the claimant’s wife. We have lived together for 14 years. I see her every day, all day.” The consequence of writing “a lot” is that DDS cannot judge how much weight to give your answers. A common misconception is that this is just a contact section, but the frequency-and-duration line shapes credibility.

A real-world example: Carlos, the claimant’s adult son, wrote “I see my dad three to four times per week for at least four hours, including weekends.” That entry let DDS treat his report as informed. The plain-English tip is to think in hours per week.

Section B: Information About the Disabled Person

Here you describe the claimant’s illnesses, injuries, or conditions and how they limit work and daily life. List every diagnosis you know about, then explain how each one limits the person. Tie the limit to the body part or mental function. The Listing of Impairments (the Blue Book) shows what SSA looks for.

The consequence of listing only one condition when there are several is that DDS may miss a combined effects analysis required by 20 C.F.R. § 404.1523. A real-world example: Priya, a friend, only mentioned diabetes and missed the claimant’s depression, so DDS never weighed the mental side. A common misconception is that mentioning extra conditions weakens the claim, but combined impairments often tip the case.

Section C: Information About Daily Activities

This is the longest and most important section. It asks you to describe a typical day from waking up to going to sleep. Use a timeline. Write what the claimant does, what they cannot do, and who helps. Mention naps, breaks, dropped tasks, and pain flares.

Then the form asks about activities the claimant did before the condition versus now. The plain-English idea is before-and-after. The consequence of skipping the before part is that DDS cannot see the loss. A real-world example: Tom wrote that his wife “used to hike five miles every Saturday and now cannot walk to the mailbox without resting twice.” That sentence is gold for DDS. A common misconception is that you should describe only the worst day, but SSR 16-3p wants a realistic picture across good and bad days.

Sleep, Personal Care, and Meals

Describe how the condition affects sleep — pain wake-ups, nightmares, sleep apnea, medication grogginess. Then walk through dressing, bathing, hair care, shaving, feeding, using the toilet, and other personal care. List who helps and how long each task now takes. For meals, say what the claimant cooks, how often, and how long it takes, and whether someone else now does it.

The consequence of writing “normal” anywhere in this part is that DDS treats it as no limit. A real-world example: Lin wrote that her husband “can shower only with a bench and needs help washing his back and feet because he cannot bend or balance.” A common misconception is that needing reminders does not matter, but reminders for grooming or meds are a Blue Book mental-listing factor under Listing 12.00.

House and Yard Work

Tell SSA what chores the claimant still does, what they cannot do, and how long the chores take. Include sweeping, laundry, dishes, trash, mowing, gardening, and home repairs. Note breaks, help, and pain afterward. The consequence of saying “does light chores” is that DDS imagines a person who could handle a sit-down job. A real-world example: Renee wrote, “My brother folds laundry for 10 minutes, then must lie down for 30 minutes due to back pain.” A common misconception is that doing any chore disproves disability, but pace, breaks, and post-task recovery matter under SSR 96-8p.

Going Outside and Travel

Say how often the claimant leaves home, how they travel, whether they drive, whether they go alone, and whether they shop. If they cannot drive, say why — seizures, panic, vision, pain, medication. The consequence of writing “goes out sometimes” is a wasted line. A real-world example: Ahmed wrote, “My mother leaves the apartment only for medical visits, about twice a month, and I drive her because vertigo makes her unsafe behind the wheel.” A common misconception is that going to a doctor counts as social activity, but SSA treats medical trips separately.

Hobbies and Social Activities

Describe what the claimant used to enjoy and what they now do. List how often, with whom, and any problems. Mention canceled plans, withdrawal, and irritability. The consequence of saying “watches TV” without context is that DDS may infer good attention. A real-world example: Beth wrote, “My husband used to coach Little League. Now he watches TV but loses the plot after 15 minutes due to PTSD-related concentration loss.” A common misconception is that hobbies hurt a claim, but limited or modified hobbies often support a claim under the paragraph B mental criteria.

Section D: Information About Abilities

This part lists physical and mental abilities and asks how each is affected. The list includes lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, talking, hearing, stair climbing, seeing, memory, completing tasks, concentration, understanding, following instructions, using hands, and getting along with others.

For each box you check, explain. Numbers help. Write “can stand 10 minutes before needing to sit”, “can walk one block before resting five minutes”, “can lift a gallon of milk but not a laundry basket”. The consequence of checking boxes without explanations is that DDS gives the form little weight. A real-world example: Greg wrote, “My wife can sit 20 minutes before her sciatica forces her to stand. She must alternate every 20 minutes.” A common misconception is that you need exact medical numbers, but careful estimates from daily life are accepted under 20 C.F.R. § 404.1529.

Physical Abilities in Detail

Cover lifting limits in pounds or household items, walking distance and recovery time, sitting and standing tolerance, reaching overhead and forward, handling and fingering small objects, and stair climbing with or without rails. Mention falls, drops, and assistive devices like canes, walkers, or braces.

The consequence of leaving out an assistive device is that DDS may not credit a medically required hand-held assistive device under SSR 96-9p. A real-world example: Kayla wrote, “My mom uses a four-wheel walker prescribed by Dr. Patel after two falls in 2025.” A common misconception is that only doctors can mention devices, but third-party observation is valid evidence.

Mental Abilities in Detail

Address memory (forgets meds, appointments, names), task completion (starts but does not finish), concentration (loses focus after how many minutes), understanding written and spoken instructions (must repeat, must write down), and getting along with others (arguments, isolation, fear of crowds). These map to the paragraph B areas in Listing 12.00: understand/remember/apply, interact, concentrate/persist/maintain pace, and adapt/manage.

The consequence of vague mental-health answers is that DDS rates limits as mild by default. A real-world example: Sergio wrote, “My brother needs three reminders to take his morning meds and still misses doses twice a week.” A common misconception is that visible behavior is the only proof, but third-party reminders and re-explanations are exactly what SSA needs.

Section E: Stress, Routine Changes, and Unusual Behaviors

This section asks how the claimant handles stress, routine changes, and whether they have unusual fears or behaviors. Write specific triggers, reactions, and frequencies. Note panic attacks, meltdowns, isolation, paranoia, hallucinations, and any harm to self or others.

The consequence of skipping this part is that mental claims look weaker than they are. A real-world example: Anna wrote, “When his routine changes, my husband shuts down for two to three days, will not speak, and refuses meals.” A common misconception is that you must use clinical labels, but plain descriptions are preferred per SSR 16-3p.

Section F: Medications and Side Effects

List every medication the claimant takes for any condition, who prescribed it, and the side effects you have seen, not what the bottle says. Drowsiness, nausea, dizziness, tremors, mood swings, and weight changes can all limit work.

The consequence of leaving this blank is that SSA may not consider side effects in the residual functional capacity (RFC) analysis under SSR 96-8p. A real-world example: Marcus wrote, “Gabapentin makes my dad nap two hours every afternoon.” A common misconception is that only the claimant should report side effects, but third-party observation is often more reliable.

Section G: Remarks

Use this open box. Add anything that did not fit. Mention bad days versus good days, hospitalizations, ER visits, and any crisis events. Reaffirm the frequency, intensity, and duration of symptoms — the SSA’s own credibility framework.

The consequence of leaving Remarks blank is a missed chance to tie the story together. A real-world example: Hannah used Remarks to describe her sister’s three psychiatric hospitalizations in 2025 and 2026, which DDS otherwise might have overlooked. A common misconception is that Remarks is optional filler, but advocates often call it the most powerful section.

Section H: Signature and Date

Sign, print your name, write the date, and add your phone. An unsigned form can be returned, which delays the case. The consequence of dating it wrong or skipping the signature is a kicked-back form. A real-world example: Ben mailed an unsigned report and lost three weeks. A common misconception is that an electronic signature on a printed PDF is fine, but SSA wants a handwritten or signed iClaim e-signature submission.

Three Most Common Real-World Scenarios

Reporter Situation	Outcome at DDS
Spouse writes detailed daily timeline with specific minutes, pounds, and named tasks	DDS gives the report substantial weight and often aligns RFC with stated limits
Adult child writes one-line answers like “cannot do much” with no examples	DDS gives little weight and relies mostly on medical records, raising denial risk
Friend writes glowing answers describing the claimant as “doing fine most days”	DDS uses inconsistencies to reduce the claimant’s own credibility under SSR 16-3p

Common Mistake on the Form	Direct Consequence
Skipping Section G Remarks	Loses the chance to tie symptoms to frequency, intensity, and duration
Checking boxes without written explanations	Examiner treats answers as conclusory and gives little weight
Contradicting the claimant’s own SSA-3373-BK	Both reports lose credibility under symptom-evaluation rules

Filing Choice	Effect on Claim Timeline
Returning the form within 10 days by mail or fax	Keeps initial decision on track, often 3 to 6 months
Uploading via SSA online portal	Same-day receipt and faster examiner review
Missing the deadline entirely	DDS may decide without the report, leading to likely denial and 12-plus-month appeal

Three Named Examples Done Right

Lisa Hernandez, wife of a claimant with multiple sclerosis, wrote that her husband “can stand for eight minutes before his right leg gives out, drops a coffee mug about twice a week from hand numbness, and naps 90 minutes every afternoon due to fatigue.” DDS aligned the RFC with a less than sedentary finding and approved the claim under Listing 11.09.

Robert Chen, father of a 28-year-old daughter with bipolar I disorder, wrote that his daughter “sleeps 14 hours during depressive weeks, cannot leave the apartment for 3 to 5 days at a time, and had two psychiatric admissions in the past year.” DDS used the report with the medical record to find marked limits in two paragraph B areas under Listing 12.04.

Janelle Brooks, longtime caregiver to a claimant with PTSD and traumatic brain injury, wrote about “three reminders for meds, two missed appointments per month despite phone alerts, and panic attacks every time the doorbell rings.” DDS credited the report at the hearing level, and the administrative law judge (ALJ) issued a fully favorable decision.

Mistakes to Avoid on Form SSA-3377-BK

Filling out this form looks easy, but small errors sink claims. Below are the most damaging missteps and what each one costs.

Writing “I don’t know” instead of “I have not observed this” — the first looks evasive and reduces weight.
Using vague words like “sometimes”, “a little”, or “normal” — DDS reads them as no limit and lowers credibility.
Contradicting the claimant’s own SSA-3373-BK — under SSR 16-3p, inconsistency damages both reports.
Painting only the worst day — DDS spots exaggeration and discounts the entire report.
Painting only good days to “not look bad” — this gives DDS reason to deny.
Skipping Section G Remarks — you lose the most flexible space to add critical detail.
Forgetting medications and side effects — this strips the RFC of important limits under SSR 96-8p.
Failing to mention assistive devices — DDS may not credit a cane or walker without your note plus medical proof.
Missing the 10-day return window — DDS can decide without you, often denying the claim.
Leaving the form unsigned or undated — SSA returns it and the case stalls.
Not tying limits to specific body parts or mental functions — DDS cannot map answers to the Blue Book listings.
Forgetting to mention how long tasks take now versus before — the before-and-after is essential.

Do’s and Don’ts

These rules separate strong reports from weak ones. Each comes with a short why.

Do use specific minutes, pounds, blocks, and counts, because DDS examiners rely on numbers to set the RFC.
Do describe a typical day hour by hour, because POMS DI 22510.006 directs examiners to look for daily-activity detail.
Do name medications and side effects you have witnessed, because side effects shape the RFC under SSR 96-8p.
Do mention assistive devices and who prescribed them, because of SSR 96-9p.
Do keep a copy and a return-receipt mailing record, because lost forms happen and you may need proof at the hearing level.
Don’t guess at medical diagnoses you do not know, because mistakes here hurt credibility under SSR 16-3p.
Don’t copy the claimant’s SSA-3373-BK word for word, because DDS reads matching reports as coached.
Don’t use medical jargon you cannot explain, because plain language carries more weight.
Don’t leave any question blank — write “N/A — I have not observed” instead, because blanks look like evasion.
Don’t add opinions about whether the claimant should get benefits, because that decision belongs to DDS and the ALJ.

Pros and Cons of Filing the Form Yourself

Many third parties wonder whether to ask a lawyer or advocate to help. Here are the trade-offs.

Pro: You know the claimant’s daily life better than any outsider, which makes the report authentic.
Pro: You save the claimant money — most disability attorneys charge a contingent fee under the 25% / $9,200 cap.
Pro: A timely report keeps the case on the initial-decision track, often 3 to 6 months.
Pro: You can update SSA later if the condition worsens, by submitting a statement to the file.
Pro: You build a usable record for any later reconsideration or hearing.
Con: Without coaching, you may write too generally and weaken the claim.
Con: Strong feelings can lead to over-statement, which DDS spots quickly.
Con: You may forget to keep a copy and lose the trail.
Con: You may misunderstand the form’s paragraph B mental criteria and miss key answers.
Con: Without legal review, you may contradict the medical record without realizing it.

Federal Versus State Nuances

SSA-3377-BK is a federal form used in every state and U.S. territory. The form text does not change by state. The plain-English meaning is that the substance of the report follows federal rules, including Title II for SSDI and Title XVI for SSI. The consequence of treating the form as a state document is that you may waste time looking for state-specific guidance that does not exist.

State Disability Determination Services offices, however, do the actual review under contract with SSA. Each state DDS may have its own intake habits, fax lines, and upload portals. For example, California DDS and Texas DDS accept uploads through different paths, but the legal standards are identical. A common misconception is that some states are easier, but SSA published statistics show that approval differences track medical evidence quality, not geography.

A few states run short-term state disability programs (California, New Jersey, New York, Rhode Island, Hawaii, and the District of Columbia for paid family leave). Those programs use different forms and do not replace SSA-3377-BK. The consequence of confusing them is missing the federal deadline. A real-world example: Ravi in New Jersey filled out a state Temporary Disability Insurance form thinking it would cover SSA, and his federal claim was denied for non-response.

How SSA Uses Your Answers

DDS examiners and ALJs read the form alongside medical records and the claimant’s own report. They build a Residual Functional Capacity (RFC) under 20 C.F.R. § 404.1545. The RFC drives the step-four and step-five analysis under the five-step sequential evaluation. Your numbers — minutes standing, pounds lifted, blocks walked — often become RFC limits.

The consequence of strong, specific answers is that the RFC matches the real-world picture. A real-world example: Whitney wrote that her husband “cannot lift more than five pounds with his right arm after rotator-cuff repair”, and DDS adopted a five-pound right-arm limit. A common misconception is that the claimant’s medical records overrule third-party answers, but SSR 16-3p treats consistent third-party reports as supportive evidence.

In key court cases like Sloan v. Astrue, 499 F.3d 883 (8th Cir. 2007) and Robinson v. Barnhart, 366 F.3d 1078 (10th Cir. 2004), federal courts reversed denials when ALJs ignored credible third-party statements. The plain-English lesson is that your form can become powerful evidence on appeal. A common misconception is that ALJs can quietly skip the report, but the Robinson line of cases requires explicit reasons for rejecting it.

Step-by-Step Filing Process

Before writing a single answer, gather background notes. The plain-English steps below match SSA’s filing guidance.

Read the entire form once before answering anything.
Sit with the claimant or review your own observations from the past 6 to 12 months.
Draft answers on scrap paper to avoid scratch-outs on the official form.
Use specific numbers — minutes, pounds, blocks, hours, days per week.
Compare your draft to the claimant’s SSA-3373-BK for honest consistency.
Fill in the form in blue or black ink, or type it as a fillable PDF.
Sign, date, and add your phone in Section H.
Make a complete copy for your records.
Submit by the method on the cover letter — mail, fax, or upload through my Social Security.
Follow up in 10 business days with the local field office to confirm receipt.

The consequence of skipping any step is delay or denial. A real-world example: Olivia skipped the copy step, and when SSA lost the form, she had to redo it from memory two months later. A common misconception is that uploading is less secure than mailing, but the SSA upload portal uses the same protections as tax filings.

Key People and Entities You Should Know

Claimant — the person seeking SSDI or SSI benefits, who fills out SSA-3373-BK.
Third-Party Reporter — you, the person filling out SSA-3377-BK.
Field Office — the local SSA field office that intakes claims.
Disability Determination Services (DDS) — the state agency that decides medical eligibility under 20 C.F.R. § 404.1503.
Disability Examiner — the DDS staffer who reads your report and the medical record.
Medical Consultant — the doctor or psychologist at DDS who advises on impairment severity.
Administrative Law Judge (ALJ) — the hearing officer who decides appeals after reconsideration.
Appeals Council — the final administrative review before federal court.
Vocational Expert (VE) — a witness at hearings who applies your stated limits to the Dictionary of Occupational Titles or its successor.

These actors all read or rely on your answers. The consequence of treating any one of them as unimportant is a weaker case. A real-world example: Felipe tailored his report to numbers a VE could use, and at the hearing the VE conceded no jobs existed. A common misconception is that only the doctor matters, but the third-party report often tips close cases.

Recap of Important Court Rulings

Sloan v. Astrue, 499 F.3d 883 (8th Cir. 2007) — ALJ must consider third-party statements and explain weight given.
Robinson v. Barnhart, 366 F.3d 1078 (10th Cir. 2004) — silent rejection of lay testimony is reversible error.
Smolen v. Chater, 80 F.3d 1273 (9th Cir. 1996) — lay witness testimony cannot be disregarded without specific reasons germane to the witness.
Stout v. Commissioner, 454 F.3d 1050 (9th Cir. 2006) — failure to address competent lay evidence is harmful error.
Bruce v. Astrue, 557 F.3d 1113 (9th Cir. 2009) — third-party spouse testimony given strong weight.

These rulings show that courts protect well-prepared third-party reports. The consequence of an ALJ ignoring your form is reversal and remand. A common misconception is that lay reports are only helpful at the start, but they often win the case on federal-court review.

FAQs

Is Form SSA-3377-BK mandatory?

No. SSA cannot force a third party to fill it out, but if SSA mailed the form to you, refusing or ignoring it weakens the claimant’s case and often leads to denial.

Can I fill out SSA-3377-BK online?

Yes. You can complete the fillable PDF, sign it, and upload it through my Social Security or fax it to the DDS number on the cover letter.

Do I need to be a U.S. citizen to fill it out?

No. Citizenship is not required for the third-party reporter. SSA only needs honest, firsthand observations of the claimant’s daily life.

Should I match the claimant’s answers exactly?

No. Mirroring answers makes both reports look coached and reduces credibility under SSR 16-3p. Write your own honest observations.

Will my answers be shared with the claimant?

Yes. Under the Privacy Act and SSA’s disclosure rules, the claimant can request the file and read your report.

Can a paid caregiver fill out SSA-3377-BK?

Yes. Paid caregivers are valid non-medical sources under 20 C.F.R. § 404.1513(a)(4) when they have frequent, recent contact with the claimant.

Does SSA pay me to fill out the form?

No. Third-party reporters receive no payment. The form is a civic and family duty, but accuracy can directly affect a loved one’s benefits.

Is there a penalty for false answers?

Yes. Knowingly false statements can lead to fines and imprisonment under Section 1001 of Title 18 and SSA’s own fraud rules.

Can I update the form after I send it?

Yes. Send a written update to the field office or DDS, reference the claim number, and ask that it be added to the file.

Does SSA-3377-BK apply to children’s claims?

No. Children’s claims use Form SSA-3375-BK and Form SSA-3376-BK. SSA-3377-BK is the adult third-party version.

Do I have to answer every question?

Yes. Leave none blank. Use “N/A — not observed” if you truly do not know, because blanks look like avoidance to DDS examiners.

Will my report be used at the appeal hearing?

Yes. ALJs review every prior third-party report and, under Sloan v. Astrue, must explain how much weight they give it.

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