Form SSA-795 Statement of Claimant or Other Person

Form Approved
OMB No. 0960-0045

SOCIAL SECURITY ADMINISTRATION

STATEMENT OF CLAIMANT OR OTHER PERSON
NAME OF WAGE EARNER, SELF-EMPLOYED PERSON, OR SSI CLAIMANT

SOCIAL SECURITY NUMBER

NAME OF PERSON MAKING STATEMENT (If other than above wage earner,
self-employed person, or SSI claimant)

-

RELATIONSHIP TO WAGE EARNER,
SELF-EMPLOYED PERSON, OR SSI CLAIMANT

Understanding that this statement is for the use of the Social Security Administration, I hereby
certify that -

Form SSA-795 (8-2002) ef (12-2005) Destroy Prior Editions

See Revised PRA Attached

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. §3507, as amended
by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid
Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions,
gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social
Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore,
MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.
SIGNATURE OF PERSON MAKING STATEMENT
Date (Month, day, year)

Signature (First name, middle initial, last name) (Write in ink)

Telephone Number (Include Area Code)

SIGN
HERE

(

)

-

Mailing Address (Number and street, Apt. No., P.O. Box, Rural Route)

City and State

ZIP Code

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the individual must sign below, giving their full addresses.
1. Signture of Witness

2. Signture of Witness

Address (Number and street, City, State, and ZIP Code)

Address (Number and street, City, State, and ZIP Code)

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 15
minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The
office is listed under U. S. Government agencies in your telephone directory or you
may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.

PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Section 205a of the Social Security Act (42 U.S.C. § 405a), as amended, authorizes us to collect the
information on this form. We will use this information to determine your potential eligibility for benefit
payments.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
requested information may affect our ability to evaluate the decision on your claim.
We rarely use the information you provide for any purpose other than for determining entitlement to
benefit payments. However, we may use the information you give us for the administration and
integrity of our programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include, but are not limited to, the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to
the Government Accountability Office and the Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs
at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies. We use
the information from these programs to establish or verify a person’s eligibility for federally-funded or
administered benefit programs and for repayment or incorrect payments or delinquent debts under
these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of Records
Notices, 60-0089, Claims Folders Systems. This notice and additional information regarding our
programs and systems are available online at www.socialsecurity.gov or at your local Social Security
office.