Information Collection

Statement of Claimant or Other Person

IC 43690 under ICR 200901-0960-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form SSA-795 Statement of Claimant or Other Person	Form
Notice Person Statement--MSSICS Screens.pdf	Other-Internal Use Screens
SSA-795 Statement of Claimant or Other Person SSA-795.pdf	Form

IC Title:

Statement of Claimant or Other Person

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.702 20 CFR 416.570

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internal Use Screens			Notice Person Statement--MSSICS Screens.pdf		Yes	Yes	Fillable Fileable Signable
Form	SSA-795	Statement of Claimant or Other Person	SSA-795.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 305,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	305,500	305,500
Annual IC Time Burden (Hours)	76,375	76,375
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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