Information Collection

Statement of Claimant or Other Person

IC 43690 under ICR 201803-0960-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Revised PA Statement.pdf	Other-Revised PA Statement
SSI Claim System Remarks Screen.pdf	Other-SSI Claim System Remarks Scree
SSA-795 Statement of Claimant or Other Person SSA-795 - Revised.pdf	Form
SSA-795 - Current.pdf SSA-795 - Current	IC Document

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-795	Statement of Claimant or Other Person	SSA-795 - Revised.pdf	No		Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf	No		Fillable Printable
Other-SSI Claim System Remarks Screen			SSI Claim System Remarks Screen.pdf	Yes	Yes	Fillable Fileable

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
SSA-795 - Current	SSA-795 - Current.pdf	06/13/2018

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