Statement of Claimant or Other Person

OMB 0960-0045

SSA uses the SSA-795 to obtain information from claimants or other persons having knowledge of facts in connection with claims for Social Security benefits or Supplemental Security Income (SSI) payments when there is no standard form to collect the needed information. SSA then uses the information to process claims for benefits or for ongoing issues related to the above programs. The respondents are applicants and recipients, or others having knowledge of facts in connection with claims for Social Security or SSI.

The latest form for Statement of Claimant or Other Person expires 2021-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-795 Statement of Claimant or Other Person (Paper /in-office interview) Form
Supporting Statement - 0045 (Final).docx Supporting Statement A
Addendum - 0045.docx Supplementary Document
Statement of Claimant or Other Person (Paper /in-office interview) Form
Statement of Claimant or Other Person (Telephone interviews) Other-SSI Claim System Remarks Screen

All Historical Document Collections

202110-0960-001 Approved with change	Revision of a currently approved collection	2021-11-02
201803-0960-004 Approved without change	Revision of a currently approved collection	2018-07-27
201503-0960-010 Approved without change	Revision of a currently approved collection	2015-07-20
201205-0960-004 Approved without change	Revision of a currently approved collection	2012-08-15
200901-0960-011 Approved without change	Revision of a currently approved collection	2009-07-14
200606-0960-021 Approved without change	Extension without change of a currently approved collection	2006-06-22
200308-0960-004 Approved without change	Extension without change of a currently approved collection	2003-08-22
200007-0960-003 Approved without change	Extension without change of a currently approved collection	2000-07-14
199706-0960-005 Approved without change	Extension without change of a currently approved collection	1997-06-13
199605-0960-012 Approved without change	No material or nonsubstantive change to a currently approved collection	1996-05-10
199512-0960-009 Approved without change	No material or nonsubstantive change to a currently approved collection	1995-12-08
199503-0960-009 Approved with change	No material or nonsubstantive change to a currently approved collection	1995-03-31
199405-0960-004 Approved without change	Extension without change of a currently approved collection	1994-05-31
199103-0960-001 Approved without change	Extension without change of a currently approved collection	1991-03-08
199002-0960-002 Approved without change	Revision of a currently approved collection	1990-02-15
198804-0960-004 Approved with change	No material or nonsubstantive change to a currently approved collection	1988-04-01
198703-0960-003 Approved without change	Revision of a currently approved collection	1987-03-11
198405-0960-011 Approved without change	Extension without change of a currently approved collection	1984-05-22
198107-0960-010 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-07-17
198008-0960-003 Approved without change	Revision of a currently approved collection	1980-08-20
197910-0960-004 Approved with change	No material or nonsubstantive change to a currently approved collection	1979-10-30
197805-0960-004 Approved without change	Extension without change of a currently approved collection	1978-05-16
197804-0960-009 Approved with change	No material or nonsubstantive change to a currently approved collection	1978-04-19
197802-0960-008 Approved without change	Extension without change of a currently approved collection	1978-02-01