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Statement of claimant or other person example

Statement of claimant or other person example 2025

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The document is a form from the Social Security Administration (SSA) titled 'Statement of Claimant or Other Person.' It is used to report out-of-pocket expenses related to medications for individuals with disabilities who are applying for Supplemental Security Income (SSI) benefits. The form requires details about the claimant's medications, associated costs, and proof of these expenses. It also includes privacy information regarding the use of personal data provided in the form.

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Click ‘Get Form’ to open the statement of claimant or other person example in the editor.
Begin by entering the name of the wage earner, self-employed person, or SSI claimant at the top of the form. Ensure accuracy as this information is crucial for processing.
Next, input the Social Security Number associated with the claimant. This step is vital for identification purposes.
If you are not the wage earner, provide your name and relationship to them in the designated fields. This helps clarify your connection to the claim.
In the section regarding out-of-pocket expenses, list any monthly costs that are not reimbursed. Attach proof such as receipts directly within our platform for convenience.
Detail any medications taken for disabilities that enable you to work. Include average monthly expenses and ensure all information is accurate and complete.
Finally, sign and date the form on the back. If necessary, include witness signatures if you signed by mark (X).

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