Supporting Statement - 0045

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 support fact-finding to process claims for benefits, and to address issues about continuing eligibility; ongoing benefit amounts; fraud investigations; and a myriad of other program‑related matters.

When SSA requires this information and is not collecting it in person or over the phone, the Field Office technician mails the respondent a blank SSA-795 along with a generic free formatted letter explaining the type of personal information the agency is seeking (e.g., to corroborate a fact alleged by the claimant).

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: filling out the paper version or during an SSI claim’s interview. Individuals can obtain the paper version either by visiting the local office or downloading the pdf fillable copy from the SSA website and mail it to SSA. An SSA technician may collect the information during an SSI application interview using the Consolidated Claims Experience (CCE) System where a technician records the individual’s statement into the Claims System and obtains a signature using either through a verbal attestation procedure or wet signature if an individual insists on using wet signature instead.

SSA does not note any psychological costs for this information collection. The SSA‑795, Statement of Claimant or Other Person allows the applicant, claimant, or other persons to complete the form in special situations where there is no authorized form or questionnaire, yet we require a signed statement. As this is a known expectation, the respondents have not indicated any specific psychological costs for this information collection. SSA uses the applicant, claimant, or other persons’ recorded statement to support fact-finding to process claims for benefits.

Respondents are applicants for Social Security, SSI, or recipients of these programs, as well as friends and relatives of the involved parties; coworkers; neighbors; or anyone else in a position to provide information pertinent to the issue(s) SSA needs addressed using the SSA-795.

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 SSI Consolidated Claims Experience (CCE) system which provides an electronic version of the SSA-795 and allows the technician to record the individual’s statement as part of the SSI application interview. Based on our data, we estimate approximately 10% of the SSA-795 statements under this OMB number are recorded using the personal interview method. Finally, the SSA-795 is currently available in Upload Documents (OMB No. 0960-0830) for electronic submission using eSignature.

Note: We do not make a distinction in the chart below between the respondents who use the paper version and the respondents who submit through Upload Documents, as, currently, more respondents are using the paper version. However, we will keep track of the management information data to see when more respondents begin to use the Upload Documents version.

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.

5. Minimizing Burden on Small Respondents

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

6. 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.

7. 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.

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

The 60-day advance Federal Register Notice published on February 12, 2025, at 90 FR 9488, and we received no public comments. The 30-day FRN published on April 16, 2025, at 90 FR 16050. 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.

9. 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.

11. Justification for Sensitive Questions

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

12. 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	154,318	1	15	38,580	$13.30*	23**	$1,299,876***
SSA-795 (SSI CCE interviews)	22,516	1	15	5,629	$32.66*	21**	$441,237***
Totals	176,834			44,209			$1,741,113***

* We based this figure on the average DI payments based on SSA's current data (https://www.ssa.gov/legislation/2024FactSheet.pdf) and on the average U.S. worker’s hourly wages, as reported by Bureau of Labor Statistics data (Occupational Employment and Wage Statistics).

** We based these figures on both the average FY 2025 wait times for field offices (23 minutes) and teleservice centers (21 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)****
154,318	1	30	77,159	$1,026,215****

****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 calculated the following Learning Cost time burden based on the estimated time and effort we expect respondents will take to learn about this program, its applicability to their circumstances, and to cover any additional research we believe respondents may need to take to understand how to comply with the program requirements (beyond reading the instructions on the collection instrument):

Modality of Completion	Total Number of Respondents	Frequency of Response	Estimate Learning Cost (minutes)	Estimated Total Annual Burden (hours)	Total Annual Learning Cost (dollars)*****
SSA-795 Paper	154,318	1	3	7,716	$102,623*****
SSA-795 (SSI CCE interviews)	22,516	1	3	1,126	$36,775*****
Totals	176,834			8,842	$139,398*****

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

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 15 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 44,209 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $2,906,726. SSA does not charge respondents to complete our forms.

13. Annual Cost to the Respondent

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

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $1,182,995. 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	$1,360
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$0*
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$1,176,817
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0*
Systems Development, Updating, and Maintenance	GS-12 employee x man hours for development, updating, maintenance	$6,178
Quantifiable IT Costs	Any additional IT costs	$0*
Total		$1,182,995

* 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.  We use an estimated average processing time of (15) minutes for these calculations. 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.

15. Program Changes or Adjustments to the Information Collection Request

The figures listed in #12 show the majority of respondents use the paper version of the SSA-795. We last cleared this IC in 2022, the burden was 57,959 hours. However, we are currently reporting a burden of 44,209 hours. This change stems a decrease in the number of responses from 231,822 to 176,834 due to the COVID-19 pandemic as SSA suspended several workloads requiring Personal Statements. 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 obtained during the CCE SSI interview which has increased the total burden.

* Note: The total burden reflected in ROCIS is 150,785, while the burden cited in #12 of the Supporting Statement is 44,209. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, one-way, drive burden + learning costs. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. 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.

18. 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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