Statement of Claimant or Other Person

Forms and Documents

Document Name	Status
Form SSA-795 Statement of Claimant or Other Person (Paper /in-office interview) Form	Modified
Supporting Statement - 0045 (Final).docx Supporting Statement A	2021-11-01
Addendum - 0045.docx Supplementary Document	2021-10-29

IC Document Collections

IC ID	Document Title	Status
43690	Statement of Claimant or Other Person (Paper /in-office interview) Form	Modified
250002	Statement of Claimant or Other Person (Telephone interviews) Other-SSI Claim System Remarks Screen	New

ICR Details

OMB Control No: 0960-0045	ICR Reference No: 202110-0960-001
Status: Received in OIRA	Previous ICR Reference No: 201803-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Claimant or Other Person
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/02/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	11/30/2021
Responses	231,822	305,500
Time Burden (Hours)	161,575	76,375
Cost Burden (Dollars)	0	0

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Abstract: SSA uses the SSA-795 to obtain information from claimants or other persons having knowledge of facts in connection with claims for Social Security benefits or Supplemental Security Income (SSI) payments when there is no standard form to collect the needed information. SSA then uses the information to process claims for benefits or for ongoing issues related to the above programs. The respondents are applicants and recipients, or others having knowledge of facts in connection with claims for Social Security or SSI.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 46897	08/20/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 59262	10/26/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Statement of Claimant or Other Person (Paper /in-office interview)	SSA-795	Statement of Claimant or Other Person
Statement of Claimant or Other Person (Telephone interviews)

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	231,822	305,500	0	0	-73,678	0
Annual Time Burden (Hours)	161,575	76,375	0	0	85,200	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: When we last cleared this IC in 2018, the burden was 76,375 hours. However, we are currently reporting a burden of 57,956 hours. This change stems a decrease in the number of responses from 305,500 to 231,822. The figures listed in #12 show the majority of respondents use the paper version of the SSA-795. Due to the COVID-19 pandemic, SSA suspended several workloads requiring Personal Statements, therefore decreasing the number of respondents submitting the paper version of the SSA-795. There is no change to the burden time per response. These figures represent current Management Information data. We also added an additional 30 minutes for travel time for the SSA-795 (paper/in-person interview) version.

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Annual Cost to Federal Government: $1,339,645

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/02/2021

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