The SSA-795 form is a document used by the Social Security Administration to collect information about an individual's work history, medical conditions, and other relevant details. This form assists in the evaluation of claims for Social Security benefits. For assistance in filling out the form, please click the button below.
The SSA-795 form, officially known as the Statement of Claimant or Other Person, plays a crucial role in the Social Security Administration's (SSA) processes. This form is primarily used when individuals need to provide additional information or clarify details related to their claims for Social Security benefits. It is particularly useful for reporting changes in circumstances, such as changes in income, living arrangements, or medical conditions that may affect eligibility. Additionally, the SSA-795 can be utilized by third parties, such as family members or guardians, to assist claimants in providing necessary information. By ensuring that all relevant details are accurately captured, the SSA-795 helps facilitate timely and appropriate decisions regarding benefit claims. Understanding how to correctly complete this form is essential for anyone navigating the complexities of Social Security benefits, as it can significantly impact the outcome of a claim.
Form SSA-795 (06-2022) UF
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Discontinue Prior Editions
Form Approved
Social Security Administration
OMB No. 0960-0045
STATEMENT OF CLAIMANT OR OTHER PERSON
Name of Wage Earner, Self-employed Person, or SSI Claimant
Social Security Number
Name of Person Making Statement (If other than above wage earner,
Relationship to Wage Earner, Self-Employed
self-employed person, or SSI claimant)
Person, or SSI Claimant
Understanding that this statement is for the use of the Social Security Administration, I hereby certify that -
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I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or imprisonment.
SIGNATURE OF PERSON MAKING STATEMENT
Signature (First name, middle initial, last name) (Write in ink)
Date (Month, day, year)
Telephone Number (Include Area Code )
Mailing Address (Number and street, Apt. No.,P.O.Box, Rural Route)
City and State
ZIP Code
Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the individual must sign below, giving their full addresses.
1. Signature of Witness
2. Signature of Witness
Address (Number and street, City, State, and ZIP Code)
Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claim filed.
We will use this information you provide to determine benefits eligibility. We may also share the information for the following purposes, called routine uses:
•To third party contacts (including private collection under contract with us), for the purpose of their assisting us in recovering overpayments; and
•To contractors and other Federal agencies, as necessary, for the purpose of assisting us in the efficient administration of our programs. We will disclose information under this routine use only in situations in which we may enter into a contractual or similar agreement to obtain assistance in accomplishing an SSA function relating to this
system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422; 60-0090, Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826; 60-0103, Supplemental Security Income Record and Special Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830; and 60-0320, entitled Electronic Disability Claim File, as published in the FR on June 4, 2020, at 85 FR 34477. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.
After obtaining the SSA SSA-795 form, it is essential to fill it out accurately to ensure that your information is processed without delay. Following the steps outlined below will guide you through the process of completing the form effectively.
What is the SSA SSA-795 form?
The SSA SSA-795 form, also known as the Statement of Claimant or Other Person, is a document used by the Social Security Administration (SSA). It allows individuals to provide information about their claims or other relevant circumstances. This form is often used when the SSA needs additional details to process a claim for benefits, such as Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).
Who needs to fill out the SSA SSA-795 form?
How do I obtain the SSA SSA-795 form?
The SSA SSA-795 form can be obtained directly from the Social Security Administration's website. It is available for download in PDF format, making it easy to print and fill out. Additionally, you can visit your local SSA office to request a physical copy of the form. If you prefer, you can also call the SSA to ask for the form to be mailed to you.
What information do I need to provide on the SSA SSA-795 form?
Can I submit the SSA SSA-795 form online?
What should I do if I make a mistake on the SSA SSA-795 form?
How long does it take for the SSA to process the SSA SSA-795 form?
Filling out the SSA SSA-795 form can be a straightforward process, but many individuals make common mistakes that can lead to delays or complications in their claims. One frequent error is not providing complete and accurate information. When details are missing or incorrect, it can cause confusion and lead to additional requests for information from the Social Security Administration.
Another mistake is failing to sign and date the form. A signature is crucial as it verifies that the information provided is true and complete. Without it, the form may be considered invalid, resulting in further delays. Additionally, people often overlook the importance of using clear and legible handwriting. Illegible writing can lead to misunderstandings about the information provided.
Some individuals neglect to review the instructions before filling out the form. Each section has specific requirements, and skipping this step can lead to incomplete submissions. Furthermore, not providing supporting documentation can hinder the process. It’s essential to include any necessary evidence that supports the claims made in the form.
People sometimes forget to keep a copy of the completed form for their records. Having a copy can be invaluable if questions arise later. Another common oversight is not checking for consistency in the information provided. Discrepancies can raise red flags and complicate the review process.
Lastly, many applicants fail to follow up after submitting the form. It’s important to ensure that the SSA has received the application and that it is being processed. Taking these steps can help avoid unnecessary delays and ensure a smoother experience with the SSA SSA-795 form.
The SSA-795 form, also known as the Statement of Claimant or Other Person, is often used to provide additional information to the Social Security Administration (SSA). Along with this form, several other documents may be required or helpful in supporting your claim. Here’s a brief overview of some commonly used forms and documents.
Gathering these forms and documents can streamline the process of applying for Social Security benefits. Having everything in order can make a significant difference in the outcome of your claim.
The SSA-795 form is used by the Social Security Administration to collect information from individuals regarding their statements or claims. Below are ten documents that share similarities with the SSA-795 form, each serving a purpose in gathering information or verifying claims.
When filling out the SSA SSA-795 form, it's essential to approach the task with care and attention to detail. This form is used to provide information about a person's work history and other relevant details for Social Security purposes. Here are some important dos and don'ts to keep in mind:
By following these guidelines, you can enhance the likelihood of a successful submission, ensuring that your application receives the attention it deserves.
The SSA SSA-795 form, officially known as the Statement of Claimant or Other Person, is often misunderstood. Here are four common misconceptions about this important document:
This is not true. While the SSA-795 is commonly used in disability claims, it can also be utilized for various other purposes, such as providing information related to retirement or survivor benefits.
While legal assistance can be helpful, it is not a requirement. Many individuals successfully complete the form on their own by carefully following the instructions provided.
In reality, this form may be required multiple times throughout your case. As circumstances change or additional information is needed, you might find yourself filling it out again.
On the contrary, the details you provide on this form can significantly impact the outcome of your claim. Accurate and complete information is crucial for the Social Security Administration to make informed decisions.
The SSA-795 form, also known as the Statement of Claimant or Other Person, is an important document for individuals applying for Social Security benefits. Here are some key takeaways to keep in mind when filling out and using this form:
By keeping these points in mind, you can navigate the process of filling out the SSA-795 form more effectively and improve your chances of a successful claim.