Statement of Claimant or Other Person

ICR 199512-0960-009

OMB: 0960-0045

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
37938 Migrated
ICR Details
0960-0045 199512-0960-009
Historical Active 199503-0960-009
SSA
Statement of Claimant or Other Person
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 12/08/1995
Retrieve Notice of Action (NOA) 12/08/1995
  Inventory as of this Action Requested Previously Approved
07/31/1997 07/31/1997 07/31/1997
308,800 0 306,700
76,960 0 76,435
0 0 0

The information collected by this form is used by the Social Security Administration (SSA) to document special circumstances in connection with a claim for benefits. The affected public consists of claimants or other persons who need to provide information to SSA that is not asked for on other forms.

None
None


No

1
IC Title Form No. Form Name
Statement of Claimant or Other Person SSA-795

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 308,800 306,700 0 2,100 0 0
Annual Time Burden (Hours) 76,960 76,435 0 525 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
12/08/1995


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