Information Collection

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

IC 43690 under ICR 202502-0960-016 · OMB 0960-0045.

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
SSA-795 - CCE Screen package.pdf	Other-SSI Claim System Remarks Scree
SSA-795 - CCE Screen package.pdf	Other-SSI Claim System Remarks Scree
SSA-795 Statement of Claimant or Other Person SSA-795.pdf	Form
SSA-795 Statement of Claimant or Other Person SSA-795.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.570 20 CFR 404.702

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	SSA-795				No		Fillable Printable
Other-SSI Claim System Remarks Screen					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: 154,318

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	154,318	-52,921	207,239
Annual IC Time Burden (Hours)	144,030	-11,399	155,429
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].