Information Collection

Statement of Claimant or Other Person (Paper /in-office interview)

IC 43690 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form SSA-795 Statement of Claimant or Other Person (Paper /in-office interview)	Form
Form SSA-795 Statement of Claimant or Other Person Statement of Claimant or Other Person (Paper /in-office interview)	Form
Privacy Act Statement 0045 (revised).docx	Other-Revised PA Statement
Privacy Act Statement 0045 (revised).docx	Other-Revised PA Statement
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 Statement of Claimant or Other Person SSA-795 (revised).pdf	Form
SSA-795 Statement of Claimant or Other Person SSA-795 (revised).pdf	Form
SSA-795 (current).pdf SSA-795 - Current	IC Document
SSA-795 (current).pdf SSA-795 - Current	IC Document
SSA-795 screen package (current).docx SSI Claim System Remarks Screen (current)	IC Document
SSA-795 screen package (current).docx SSI Claim System Remarks Screen (current)	IC Document

IC Title:

Statement of Claimant or Other Person (Paper /in-office interview)

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:

table that charts list of 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			Privacy Act Statement 0045 (revised).docx	No		Fillable Printable
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: 207,239

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	207,239	-98,261	305,500
Annual IC Time Burden (Hours)	155,429	79,054	76,375
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-795 - Current	SSA-795 (current).pdf	10/05/2021
SSI Claim System Remarks Screen (current)	SSA-795 screen package (current).docx	10/05/2021

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