Information Collection

Statement Of Claimant Or Other Person

IC 166450 under ICR 199503-0960-009 · OMB 0960-0045.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0045 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	STATEMENT OF CLAIMANT OR OTHER PERSON	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-795				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 306,700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	306,700	1,200	305,500
Annual IC Time Burden (Hours)	76,435	60	76,375
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.