Form SSA-795 "Statement of Claimant or Other Person"

Form SSA-795 Instructions

The instructions for completing the SSA Form 795 may depend on the reason you submit it. If you are not sure how to make a proper statement, visit the nearest Social Security office and an authorized official will provide you with the appropriate instructions.

If you request continuation of benefit payments while your appeal is being processed, ask an SSA officer to provide you with the SSA Form 795 (Benefit Continuation Election Statement). This version of the form will contain a pre-printed statement and a checklist. There are four main types of pre-printed statements. They depend on the type of benefits you received and wish to continue. Just read the statement, check the applicable box, sign, and date the document.

The information provided in the form must be true and correct to the best of your knowledge. Deliberate submitting of any false statement may lead to a fine or imprisonment. Submit the completed statement to your local Social Security office. Find the addresses of the offices in your telephone directory under U.S. Government Agencies, on the SSA official website, or by calling the toll-free number provided on the second page of the form.

How to Fill out SSA-795 Form?

The SSA statement of claimant is easy to complete. It takes about 15 minutes to learn the instructions, find all the necessary information, and fill out the form. The general filling out instructions for the SSA Form 795 are as follows:

• Indicate the name of the claimant in the first field;
• Provide the Social Security number of the claimant;
• If you are not the claimant, enter your name in "Name of Person Making Statement" field;
• Specify your relationship to the claimant;
• Make your statement to the SSA. It must be clear and precise, based on facts rather than opinions. Try to avoid inconsistencies;
• Hand sign your statement and indicate the date;
• Specify your telephone number with area code, and full mailing address, including city, state, and ZIP code;
• If you have signed this form with "X", find two impartial witnesses who know you to sign the form and provide their addresses.