Information Collection

Statement of Claimant or Other Person

IC 44220 under ICR 202204-3220-004 · OMB 3220-0183.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0183 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.