Statement of Claimant or Other Person

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0045 can be found here:

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.