Form SSA-795 Statement of Claimant or Other Person

What Is Form SSA-795?

Form SSA-795, Statement of Claimant or Other Person is a form used for providing the Social Security Administration (SSA) with a signed statement regarding an application for Social Security benefits or Supplemental Security Income (SSI). The latest version of the statement - also known as the SSA Form 795 - was issued by the SSA in September 2015.

An SSA-795 fillable form is available for download and digital filing below or on the SSA official website.

What Is Form SSA-795 Used for?

Form SSA-795 is most often used in case of reconsideration of an individual's eligibility to receive the SSA benefits. It may be submitted to request continuation of receiving benefits while you are working on your appeal. Besides, you can use the SSA statement of claimant form to provide a valid reason why you were not able to file your appeal in time.

The SSA uses the information you provide via the SSA-795 to process:

  • Continuing eligibility issues;
  • Determination of eligibility for Social Security benefits and SSI;
  • Use of funds by a representative payee;
  • Investigation of frauds;
  • Other program-related issues.

Submitting this form is voluntary. However, if you do not provide the requested information, it may affect the SSA ability to evaluate the decision on your claim.

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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 -
Form SSA-795 (09-2015) ef (09-2015)
Destroy 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 -
Form SSA-795 (09-2015) ef (09-2015)
Destroy Prior Editions
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)
Address (Number and street, City, State, and ZIP Code)
Privacy Act Statement
Collection and Use of Personal Information
Section 205a of the Social Security Act (42 U.S.C. § 405a), as amended, authorizes us to collect the information on this
form. We will use this information to determine your potential eligibility for benefit payments.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the requested information may
affect our ability to evaluate the decision on your claim.
We rarely use the information you provide for any purpose other than for determining entitlement to benefit payments.
However, we may use the information you give us for the administration and integrity of our programs. We may also
disclose information to another person or to another agency in accordance with approved routine uses, which include, but
are not limited to, the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the Government
Accountability Office and the Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and
local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records
with records kept by other Federal, State, or local government agencies. We use the information from these programs to
establish or verify a person’s eligibility for federally-funded or administered benefit programs and for repayment or
incorrect payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notices, 60-0089,
Claims Folders Systems. This notice and additional information regarding our programs and systems are available online
at
www.socialsecurity.gov
or at your local Social Security office.
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 control number. We estimate that it will take about 15 minutes to read
the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or
you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate
above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.
Form SSA-795 (09-2015) ef (09-2015)

Download Form SSA-795 Statement of Claimant or Other Person

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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.
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