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This version of the form is not currently in use and is provided for reference only. Download this version of
Form SSA-795
for the current year.
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 U.S. Social Security Administration (SSA) with a signed statement regarding an application for Social Security benefits or Supplemental Security Income (SSI).
Alternate Names:
- SSA Form 795;
- SSA Statement of Claimant.
The latest version of the statement was issued on September 1, 2015 . An SSA-795 fillable form is available for download and digital filing through the link below.
What Is Form SSA-795 Used For?
Form SSA-795 is most often used in case of a reconsideration of an individual's eligibility to receive the SSA benefits. It may be submitted to request the 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, and other program-related issues.
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 the continuation of benefit payments while your appeal is being processed, ask an SSA officer to provide you with Form SSA-795, Benefit Continuation Election Statement . 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. Deliberately submitting any false statements 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?
General filing instructions for the SSA Form 795 are as follows:
- 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. 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 sign the form with "X," find two impartial witnesses who know you to sign the form and provide their addresses.
Download Form SSA-795 Statement of Claimant or Other Person
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