The SSA-795 form serves as an official document used by the Social Security Administration to collect various types of statements and declarations from individuals. This form is versatile, catering to a wide range of needs, from reporting changes in income to providing proof of eligibility for benefits. Understanding how to accurately complete and submit this form is essential for individuals looking to ensure their statements are officially recorded and considered by the SSA.
The Social Security Administration (SSA) employs a variety of forms to gather necessary information from individuals applying for benefits, updating records, or making changes to their current benefits. Among these forms, the SSA-795 is particularly significant for its versatility and utility. It serves as a statement of claimant or other person, allowing individuals to provide any additional information that may impact their claims or benefits. This form can be crucial in clarifying discrepancies, elaborating on circumstances that do not fit neatly into the standard application forms, or updating personal information that could affect benefit calculations. Its role in the application process is to ensure that the SSA has a complete and accurate account of an individual's situation, making it an indispensable tool for both the administration and the applicants. Through this form, claimants have the opportunity to express in their own words any details they believe are pertinent to their case, making it a pivotal piece of documentation in the complex process of applying for or altering Social Security benefits.
Form SSA-795 (02-2020) UF
Discontinue Prior Editions
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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 (02-2020)
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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)
Mailing Address (Number and street, Apt. No.,P.O.Box, Rural Route)
Date (Month, day, year)
Telephone Number (Include Area Code )
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 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 affect our ability to properly adjudicate claims or resolve entitlement and eligibility issues.
We may use the information to make a determination on program or non-program related matters. We may also share the information for the following purposes, called routine uses:
•To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of its programs; and,
•To student volunteers and other workers, who technically do not have the status of Federal employees, when performing work for SSA as authorized by law, and they need access to personally identifiable information in SSA records in order to perform their assigned Agency functions.
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, Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784, 60-0090, Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826, and 60-0103, Supplemental Security Income Record and Special Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830. Additional information, and a full listing of all of our SORNs, is available on our website at https://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 control number. We estimate that it will take about 60 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also 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 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. Send only comments relating to our time estimate to this address, not
the completed form.
Filling out the SSA-795 form is an essential step for individuals looking to communicate specific information to the Social Security Administration (SSA). This document allows for the submission of any statements or claims that need to be clarified or updated. To ensure the form is completed accurately and effectively, follow the listed steps carefully. Once submitted, the SSA will review the information provided and take the necessary actions based on the contents of the form.
After submission, the Social Security Administration will process your form. This procedure involves verifying the information provided and making any updates or corrections to your records as indicated. You may be contacted for further information or to clarify the details you've submitted. It's crucial to respond promptly to any requests from the SSA to ensure your records are accurate and up-to-date.
What is the SSA-795 form used for?
The SSA-795 form is an official document utilized by the Social Security Administration (SSA) for individuals to provide a statement or report various kinds of information. These details can relate to employment, income, marital status, eligibility for benefits, or any other information that affects social security benefits. The form allows for a structured way to communicate changes or updates that might impact an individual's social security benefits.
How can one obtain an SSA-795 form?
This form can be easily accessed through the Social Security Administration’s official website, where it is available for download. Additionally, individuals can visit a local SSA office to obtain a paper copy. It’s also possible to request the form over the phone, and the SSA will mail it directly to the requester’s home.
Is there a filing fee for the SSA-795 form?
No, there is no filing fee associated with the SSA-795 form. The Social Security Administration does not require any payment for processing this form, whether it is submitted in person, by mail, or electronically.
What kind of information must be provided on the SSA-795 form?
The SSA-795 form requires detailed information related to the individual's specific circumstances. This might include personal identification details, employment history, income levels, marital status, and any other information that could affect one's eligibility or benefits amount. It is crucial for individuals to provide accurate and up-to-date information to avoid any potential delays or complications in the processing of their social security benefits.
Can the SSA-795 form be submitted electronically?
Yes, in many cases, the SSA-795 form can be submitted electronically via the Social Security Administration’s website. This method offers a convenient option for individuals to provide necessary information without the need to visit an SSA office. However, it's essential to check the SSA website or contact the administration directly as certain conditions may require the form to be submitted in person or by mail.
What happens after submitting the SSA-795 form?
After submission, the Social Security Administration will review the form as part of the individual's record. The provided information will be used to update their details, which may affect their benefits. The SSA may contact the individual if additional information or clarification is required. Once the review process is completed, individuals will be notified about the impact on their social security benefits.
Is assistance available for completing the SSA-795 form?
Yes, assistance for completing the SSA-795 form is available. Individuals can seek help from SSA representatives either by phone or at a local SSA office. Additionally, many community organizations and advocacy groups offer support and advice for filling out social security forms. This help can be invaluable, particularly for those who may have questions or face challenges in providing the required information.
One common mistake people make when filling out the SSA-795 form is providing incomplete information. It's crucial to fill out every required section to avoid delays in processing. Leaving blanks can lead to misunderstandings or a request for additional information, which can prolong the process.
Another error is not updating personal details, such as a change of address or phone number. This can result in important correspondence from the Social Security Administration (SSA) not reaching the applicant, potentially leading to missed deadlines or lost benefits.
Often, individuals submit the form without checking it for errors. Typos, especially in key personal information such as Social Security numbers or dates, can cause significant delays. It's important to review the form thoroughly before submission to ensure accuracy.
Failing to provide necessary documentation is another pitfall. The SSA-795 form might require supplementary documentation to support statements or claims. Neglecting to attach this documentation can result in an incomplete application process.
Some applicants mistake the purpose of the form, using it to apply for benefits for which it is not designed. Understanding the specific purpose of the SSA-795 form and ensuring it aligns with one's needs is critical before starting the application process.
Signing the form without reading the declarations and authorizations is also a common mistake. It's important to understand the legal implications and the information being certified as true before signing off on the document.
Using incorrect or outdated forms can lead to rejection. The SSA periodically updates its forms, so ensuring the most current version is used is critical for a smooth application process.
Overlooking the need for a witness signature when required is another oversight. In some cases, a witness's signature may be necessary to validate the applicant's identity or verify that the applicant understands the form's contents.
Lastly, not seeking help when needed is a frequent mistake. The SSA-795 form can be complex, and seeking clarification from the SSA or a legal advisor can prevent errors and save time in the long run.
In the process of Social Security Administration (SSA) applications or claims, a variety of forms and documents are typically utilized in conjunction with the SSA-795 form. The SSA-795 form, known for its role in allowing individuals to furnish the SSA with a written statement on various issues, often needs to be accompanied by specific additional documentation. These forms and documents help to reinforce, detail, or provide necessary evidence pertinent to an individual's claim or application, ensuring comprehensive review and consideration by the SSA.
Using these forms and documents in conjunction with the SSA-795 form allows individuals to present their case to the Social Security Administration in a comprehensive manner. Each of these documents plays a critical role in building the framework of an application or claim, ensuring that all relevant information is accounted for and properly communicated. Understanding the purpose and requirement of each will significantly aid in the smooth and efficient processing of Social Security claims.
The SSA SSA-795 form is used by the Social Security Administration (SSA) to obtain personal statements or clarify information related to an individual's Social Security records. Similar to this form, the SSA-3368 form is another document utilized in the process of applying for disability benefits. The SSA-3368 form, specifically, collects detailed information about an individual's medical condition and their work history to assess their eligibility for disability benefits. Both forms are pivotal in the application process for benefits, though they gather different types of necessary information.
Another document that mirrors the SSA SSA-795 form in its purpose is the SSA-3441 form. This form is used for Disability Report Appeals, allowing individuals to provide updated information regarding their disability, medical treatment, and work activity. Like the SSA-795, it serves as a means for individuals to supply the SSA with crucial updates that could affect their disability benefits status, thereby playing a critical role in the continuation or modification of benefits.
The IRS Form 4506-T, Request for Transcript of Tax Return, shares similarities with the SSA SSA-795 in that it's used to request personal information for verification purposes. While the SSA-795 may be used to clarify or provide personal statements to the SSA, the Form 4506-T specifically allows individuals or entities to obtain past tax return information, which can be necessary for loan applications, housing, or even verifying income for the SSA benefits application process. Both forms are instrumental in providing authoritative third parties with personal information for verification or decision-making processes.
The I-9 form, Employment Eligibility Verification, also shares a common goal with the SSA SSA-795 form in terms of verifying personal information, albeit for different reasons. The I-9 form is used by employers in the United States to verify the identity and employment authorization of individuals hired for employment. Similar to the SSA-795 form, it collects personal data to fulfill legal requirements, the former for employment purposes and the latter for Social Security purposes.
Form W-4, the Employee's Withholding Certificate, is another document that, like the SSA SSA-795, collects personal information, but with a focus on determining the correct federal income tax withholding from employees’ paychecks. Although its primary purpose diverges by being tax-related, it is akin to the SSA-795 in that it requires individuals to provide detailed personal information that affects their financial transactions, in one case affecting tax withholdings and in the other, potentially, Social Security benefits.
The Health Insurance Marketplace application is a document individuals fill out to apply for health insurance through the Marketplace, providing personal information, including income, household size, and more, to determine eligibility for health coverage options. Similar to the SSA-795 form, it's a tool through which individuals submit personal and sensitive information to a government agency to obtain a certain benefit, in this case, health insurance as opposed to Social Security benefits.
The Free Application for Federal Student Aid (FAFSA) is used by college or graduate students to apply for financial aid, requiring detailed information about an individual’s financial situation. Like the SSA SSA-795 form, the FAFSA plays a crucial role in determining eligibility for benefits — with the former concerning Social Security and the latter concerning financial aid. Both require extensive and accurate disclosure of personal and financial information to a governmental authority.
Lastly, the HUD-1 Settlement Statement, although more specific to real estate transactions, shares a conceptual similarity with the SSA-795 form. It's used in the closing of property sales to itemize services and fees charged to the borrower and seller during a real estate transaction. While fundamentally different in purpose, both forms compile critical personal and financial information necessary for completing a formal process — be it receiving benefits from the SSA or finalizing the purchase of a home.
Filling out the SSA-795 form is a crucial step in communicating your situation or any changes to the Social Security Administration (SSA). This form allows you to make statements related to your Social Security benefits. To navigate this process smoothly and accurately, here's a concise guide on what you should and shouldn't do:
Things You Should Do
Completely and accurately provide all the requested information. Ensure that your details match the information the SSA already has on file.
Use a black or blue pen for clarity. These colors are preferred because they are easier to read and photocopy.
Review your statements carefully before submission. It's essential to make sure that all the information you provide is accurate and truthful to the best of your knowledge.
Sign and date the form. Your signature provides confirmation that the information you've provided is accurate. Failure to sign may result in delays.
Keep a copy of the completed form for your records. This step is important for future reference or if any disputes arise concerning the information you have provided.
Contact the SSA directly if you have any questions or need clarification on how to complete the form. Getting help can prevent errors and ensure your form is processed smoothly.
Things You Shouldn't Do
Don't leave sections blank. If a particular section doesn't apply, write "N/A" (not applicable). Leaving blanks can cause confusion and delays.
Don't guess information. If you're unsure about certain details, it's better to verify first than to provide incorrect information.
Don't use correction fluid or tape. Mistakes should be clearly crossed out with a single line, and the correct information should be written nearby.
Don't include unnecessary personal information not requested on the form. Stick to providing only the information that is asked for.
Don't fold or staple the form. This can make it difficult to scan or copy, potentially leading to processing errors.
Don't submit without reviewing. Taking the time to double-check your form can save a lot of time and hassle in the long run.
The Social Security Administration (SSA) provides various forms that are crucial for individuals seeking benefits or needing to communicate certain information. One such form is the SSA-795, which is often surrounded by misconceptions. Understanding the purpose and use of this form is essential for accurately navigating the process.
Misconception 1: The SSA-795 form is only for reporting changes in income. While the SSA-795 form can be used to report changes in income, its use is not limited to this aspect. It is a versatile form that allows individuals to provide any statement or information that the SSA may need, covering a wide range of topics beyond just income changes.
Misconception 2: The form can only be submitted by the person receiving benefits. It's crucial to understand that not only the beneficiaries but also representatives, such as legal guardians or appointed representatives, can fill out and submit the SSA-795 form on behalf of someone else. This flexibility ensures that individuals who may need assistance have the means to relay important information to the SSA.
Misconception 3: Submitting the SSA-795 form online is an option. In today's digital age, it is a common assumption that most governmental forms can be submitted online. However, this is not the case with the SSA-795. Individuals need to either mail it to the SSA or submit it in person at a local SSA office. This ensures that the information provided is securely handled and processed.
Misconception 4: The SSA-795 form is difficult to understand and complete without professional help. Although navigating SSA forms can seem daunting, the SSA-795 is designed to be straightforward. It essentially provides a blank canvas for individuals to write or type the necessary information that they need to communicate to the SSA. Guidance on how to complete the form is available from the SSA, making it accessible for individuals to use without requiring professional assistance.
Understanding these misconceptions can greatly demystify the process of using the SSA-795 form, making it clearer for individuals who need to provide information to the SSA. Everyone's situation is unique, and tools like the SSA-795 form are there to ensure that individual needs and circumstances are communicated effectively.
The SSA-795 form is used by the Social Security Administration (SSA) to collect various types of information from individuals for different purposes. Understanding how to fill out and use this form properly is important for ensuring that your information is accurately represented to the SSA. Here are key takeaways about the SSA-795 form:
Understanding these key aspects of the SSA-795 form can help individuals navigate their interactions with the Social Security Administration more effectively. Whether you're reporting changes or providing additional information, properly completing and using this form is a crucial step in managing your benefits and obligations.
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