Supporting Statement for Form SSA-795
Statement of Claimant or Other Person
20 CFR 404.702, 20 CFR 416.570
OMB No. 0960-0045
Introduction/Authoring Laws and Regulations
Section 205(a) of the Social Security Act authorizes the Social Security Administration (SSA) to regulate and provide rules for the nature and extent of proofs and evidence, and the methods of taking and furnishing proof or evidence, to establish an individual’s eligibility to benefits. Individuals use Form SSA-795 to make signed statements relating to claims for Social Security benefits or Supplemental Security Income (SSI) payments under 20 CFR 404.702 and 416.570 of the Code of Federal Regulations. For example, 20 CFR 416.570 requires individuals’ signed statements before recovery of any overpayment or adjustment of any overpayment under Titles II, VIII, or XVIII. Recipients of any of these programs may use Form SSA-795 to elect to have an overpayment withheld from their benefits.
Description of Collection
SSA uses Form SSA-795 in special situations where there is no authorized form or questionnaire, yet, we require a signed statement from the applicant, claimant, or other persons who have knowledge of facts, in connection with claims for Social Security benefits or SSI payments. The information we request on this form is of sufficient importance that we need both a signed statement and a penalty clause. SSA uses this information to process claims for benefits, and to address issues about continuing eligibility; ongoing benefit amounts; use of funds by a representative payee; fraud investigations; and a myriad of other program‑related matters. The respondents are applicants for Social Security, SSI, or recipients of these programs. In addition, respondents also include friends and relatives of the involved parties; coworkers; neighbors; or anyone else in a position to provide information pertinent to the issue(s).
Use of Information Technology to Collect the Information
This form is available as a print-only, fillable PDF on SSA’s website. SSA also created a remarks screen in the SSI Claims System to collect this information electronically via telephone or personal interviews for SSI-related claims.
Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequences of Not Collecting Information or Collecting it Less Frequently
If we did not collect this information, SSA would not be able to fix unresolved issues from claimants or other people, as needed, to adjudicate claims, or to resolve post‑entitlement and post-eligibility issues. Because we collect this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on May 9, 2018, at
83 FR 21328, and we received no public comments. The 30-day FRN published on July 26, 2018 at 83 FR 35526. If we receive any comments in response to this Notice, we will forward them to OMB.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
Assurance of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.
Justification for Sensitive Questions
This information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Modality of Completion |
Number of Respondents |
Frequency of Response |
Average Burden per Response (minutes) |
Estimated Total Annual Burden (hours) |
SSA-795 |
305,500 |
1 |
15 |
76,375 |
The total burden for this ICR is 76,375 hours. We based these figures on current management information data. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondent
This collection does not impose a known cost burden on the respondents.
Annual Cost to the Federal Government
The annual cost to the Federal Government is approximately $470,470. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time; and (3) systems development, updating, and maintenance costs.
Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exception to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
Collection of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Barnett Roseman |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |