Statement of Claimant or Other Person

Documents and Forms

Document Name Document Type
Form G-93 (09-18) Statement of Claimant or Other Person Form
G-93 (09-18) Statement of Claimant or Other Person Form G-93 (09-18).pdf Form
G-93 (09-18) Statement of Claimant or Other Person Form G-93 (09-18).pdf Form
SSA-795 (09-2015).pdf Statement of Claimant or Other Person IC Document
SSA-795 (09-2015).pdf Statement of Claimant or Other Person IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Claimant or Other Person	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 320 20 CFR 217

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-93 (09-18)	Statement of Claimant or Other Person	Form G-93 (09-18).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System	FR Citation: 79 FR 58874

Number of Respondents: 1,300	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	Previously Approved
Annual Number of Responses for this IC	1,300	1,240	60
Annual IC Time Burden (Hours)	325	310	15
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Statement of Claimant or Other Person	SSA-795 (09-2015).pdf	04/21/2022

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