Information Collection

Statement of Claimant or Other Person (Telephone interviews)

IC 250002 under ICR 202110-0960-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
SSA-795 screen package (revised).docx Other-SSI Claim System Remarks Scree
Revised CCE Screen package for SSA-795 - 5-5-22.pdf Other-SSI Claim System Remarks Scree
SSA-795 screen package (current).docx SSI Claim System Remarks Screen IC Document
SSA-795 screen package (current).docx SSI Claim System Remarks Screen IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Claimant or Other Person (Telephone interviews)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.570 20 CFR 404.702

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SSI Claim System Remarks Screen			Revised CCE Screen package for SSA-795 - 5-5-22.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: 24,583	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	24,583	24,583
Annual IC Time Burden (Hours)	6,146	6,146
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSI Claim System Remarks Screen	SSA-795 screen package (current).docx	11/02/2021

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