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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, self-employed person, or SSI claimant) --2025

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The document is a form (SSA-795) used by the Social Security Administration for individuals to provide statements regarding claims for benefits. It includes sections for personal information, a declaration of truthfulness under penalty of perjury, and privacy information about the collection and use of personal data. The form emphasizes the importance of accurate information for determining eligibility for benefit payments.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the name of the wage earner, self-employed person, or SSI claimant in the designated field. Ensure accuracy as this information is crucial for identification.
Next, input the Social Security Number associated with the individual named above. Double-check for any errors to avoid processing delays.
If you are not the wage earner or claimant, provide your name in the section labeled 'Name of Person Making Statement.'
Indicate your relationship to the wage earner or claimant in the specified field. This helps clarify your connection and authority to make this statement.
Complete all remaining fields including signature, date, telephone number, and mailing address. If applicable, ensure two witnesses sign if you used a mark (X) for your signature.

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What is a 795 Social Security form?

Form SSA-795 is a multi-purpose form used to submit written requests to Social Security. The title of the form is "Statement of Claimant", and Social Security prefers to have people use the form as opposed to other types of correspondence because it contains a penalty clause for making false statements.

Who fills out form SSA-795?

SSA uses Form SSA-795 in special situations where there is no authorized form or questionnaire, yet we require a signed statement from the applicant, claimant, or other individuals who have knowledge of facts, in connection with claims for Social Security benefits or SSI.

Is SSI the same as Social Security?

Social Security benefits come from a fund that is created by the taxes paid into the system. SSI benefits, on the other hand, come from the U.S. Treasury's general funds. 3. Additional help with medical costs with SSI.

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Who fills out SSA-795?

Form SSA-795, Statement of Claimant or Other Person, is used by a third-party who needs to make a statement about the applicant's employment or wages.

How do you fill out a statement of claimant or other person form?

Indicate the name of the claimant in the first field. Provide the Social Security Number (SSN) of the claimant. If you are not the claimant, enter your name in the box titled "Name of Person Making Statement." Specify your relationship with the claimant. Make your statement to the SSA.

Is SSI a recipient?

SSI is for people who are 65 or older, as well as people of any age, including children, who are blind or have disabilities. To qualify for SSI, you must also have little or no income and few resources.

What is the purpose of SSA-795?

1. General information for recording statements on the SSA-795. Use an SSA-795 whenever a signed statement is required or desirable, except when we request some other form or questionnaire or we can readily adapt for the statement.

Where do I send SSA form 795?

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.

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, self-employed person, or SSI claimant) --2025

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