Supporting Statement - 0045 (Final)

Supporting Statement for Form SSA-795

Statement of Claimant or Other Person

20 CFR 404.702, 20 CFR 416.570

OMB No. 0960-0045

1. Justification

1. 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.

2. 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). Individuals can complete the SSA-795 using two modalities: paper or through a personal interview. Individuals can obtain the paper version either by visiting the SSA website and downloading the form or requesting a paper copy. In addition, an SSA technician may collect the information during an in-person application interview using the SSI Claims System and then prints the form to obtain the wet signature. The SSI Claims System version allows the SSA technician to record the individual’s statement into the Claims System and obtain a signature using either through a verbal attestation procedure or wet signature.

3. Use of Information Technology to Collect the Information

The paper form is available as a fillable PDF on SSA’s website for individuals to complete, print, sign, and submit to SSA. In addition, technicians use the Person Statement (DPST) screens in the SSI Claims Systems to collect the needed information via telephone or in-person interviews and then prints the form for the individual to sign. As part of the Information Technology (IT) Modernization Plan, SSA is moving the version of the SSA-795 from the SSI Claims system to the Consolidated Claims Experience (CCE) web-based platform. The new web‑based CCE platform will house an electronic version of the SSA-795, which allows the SSA technician to record the individual’s statement and obtain a signature using the attestation procedure instead of needing to request a wet signature. CCE will eventually replace other claims screens or other forms. Based on our data, we estimate approximately 10% of the SSA-795 statements under this OMB number are recorded using the personal interview method.

SSA is currently unable to create an Internet version of this information collection due to the form being pre-printed. SSA technicians usually enter the statement into the Claims system, to record the individual’s statement into the Claims System and obtain a signature using either through a verbal attestation procedure or wet signature. We will reassess this ability if and when technological advances are created that would allow for us to make this collection available via the Internet.  Given that IT Mod programming is an ongoing, dynamic project, we cannot provide specific timelines for when we will be able to make any particular ICR available via Internet web-based application.  We will ultimately convert most existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this may be unconnected to the PRA approval lifecycle.

In addition, we evaluated this collection for conversion to a submittable PDF, and found it is not suitable for that process either, as this information collection is unusual due to the form being pre-printed prior to our requesting the respondents submit their signed or verbally attested statement.

4. 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.

4. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

4. 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.

4. 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.

4. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on August 20, 2021, at

86 FR 46897, and we received no public comments. The 30-day FRN published on October 26, 2021 at 86 FR 59262. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the development revision of this form.

4. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. 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.

10. Justification for Sensitive Questions

This information collection does not contain any questions of a sensitive nature.

10. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Average Wait Time in Field Office or Telephone Wait Time (minutes) **	Total Annual Opportunity Cost (dollars)***
SSA-795 (Paper /in-office interview)	207,239	1	15	51,810	$10.95*	24**	$1,475,031***
SSA-795 (Telephone interviews)	24,583	1	15	6,146	$27.07*	19*	$377,112***
Totals	231,822			57,956			$1,852,143***

* We based this figure on the average DI payments based on SSA's current FY 2021 data (https://www.ssa.gov/legislation/2021FactSheet.pdf) and on the average U.S. worker’s hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes_nat.htm#00-0000).

** We based these figures on both the average FY 2021 wait times for field offices (24 minutes) and teleservice centers (19 minutes), based on SSA’s current management information data.

*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

In addition, OMB’s Office of Information and Regulatory Affairs (OIRA) is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection. OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97-mile driving distance for one-way travel. We depict this on the chart below:

Total Number of Respondents Who Visit a Field Office	Frequency of Response	Average One-Way Travel Time to a Field Office (minutes)	Estimated Total Travel Time to a Field Office (hours)	Total Annual Opportunity Cost for Travel Time (dollars)****
207,239	1	30	103,620	$1,134,639

****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the

5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.” SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data that shows that the average respondent drives to a field office, rather than using any other mode of transport. SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

NOTE: We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection. Per our management information data, we believe that 10 minutes accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. Based on our current management information data, the current burden information we provided is accurate. The total burden for this collection instrument is 57,956 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $2,986,782. SSA does not charge respondents to complete our applications.

10. Annual Cost to the Respondent

This collection does not impose a known cost burden on the respondents.

10. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $1,339,645. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$513
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$359
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$1,284,294
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0*
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$54,479
Quantifiable IT Costs	Any additional IT costs	$0*
Other	[Component may add as needed]	$0*
Total		$1,339,645

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have.  First, since we work with almost every US citizen, we often do bulk mailings, and cannot track the cost for a single mailing.  In addition, it is difficult for us to break down the cost for processing a single form, as field office and State Disability Determination Services staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

10. Program Changes or Adjustments to the Information Collection Request

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.

10. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

10. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. Upon OMB approval, SSA updates the expiration dates to the paper form available as a fillable PDF on SSA’s website. However, if an individual submits an older version with an expired date, SSA would accept it to avoid Government waste.

10. 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).

2. Collection of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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