SSA-795 - Current

Form SSA-795 (02-2020) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0045

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 (02-2020)

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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 statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.

SIGNATURE OF PERSON MAKING STATEMENT
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)
Telephone Number (Include Area Code )

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. Signature of Witness
2. Signature of Witness
Address (Number and street, City, State, and ZIP Code)

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

Privacy Act Statement
Collection and Use of Personal Information
Section 205 of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is
voluntary. However, failing to provide all or part of the information may affect our ability to properly adjudicate claims or
resolve entitlement and eligibility issues.
We may use the information to make a determination on program or non-program related matters. We may also share the
information for the following purposes, called routine uses:
•

To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient
administration of its programs; and,

•

To student volunteers and other workers, who technically do not have the status of Federal employees, when
performing work for SSA as authorized by law, and they need access to personally identifiable information in SSA
records in order to perform their assigned Agency functions.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example,
where authorized, we may use and disclose this information in computer matching programs, in which our records are
compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of
incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, Claims
Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784, 60-0090, Master Beneficiary
Record, as published in the FR on January 11, 2006, at 71 FR 1826, and 60-0103, Supplemental Security Income Record
and Special Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830. Additional information, and a
full listing of all of our SORNs, is available on our website at https://www.ssa.gov/privacy.
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 60 minutes to read
the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at
www.socialsecurity.gov. Offices are also 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 regarding this
burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not
the completed form.