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

Statement of Claimant or Other Person

Documents and Forms

Document Name Document Type
Form SSA-795 Statement of Claimant or Other Person (Paper /in-office interview) Form
SSA-795 Statement of Claimant or Other Person SSA-795.pdf Form
SSA-795 - CCE Screen package.pdf Other-SSI Claim System Remarks Screen

Information Collection (IC) Details

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

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-795	Statement of Claimant or Other Person	SSA-795.pdf		No		Fillable Printable
Other-SSI Claim System Remarks Screen			SSA-795 - CCE Screen package.pdf		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 %

	Requested	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

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.