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The SSA SSA-795 form plays a pivotal role in bridging the communication between individuals and the Social Security Administration (SSA). Designed to capture a broad spectrum of information, this versatile form allows for the submission of any statement or claim that impacts SSA decisions regarding benefits or services. From clarifications about employment history to corrections of recorded earnings and other claims, the form serves as a critical tool in ensuring accurate and fair processing. Individuals looking to provide additional evidence or rectify discrepancies in their records can utilize this form, making it an essential component of managing interactions with the SSA. By facilitating the submission of supplementary details or explanations, the SSA SSA-795 enhances the accuracy of assessments and aids in the efficient administration of benefits, showcasing its importance in the broader context of social security operations.

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Form SSA-795 (02-2020) UF

 

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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)

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.

File Characteristics

Fact Name Description
Purpose of SSA-795 The SSA-795 form is used by the Social Security Administration to allow individuals to provide a written statement about their employment or wages when official documents are not available.
Who Can Use It Any individual who needs to clarify or correct information about their earnings, or to provide additional detail to the SSA can use this form.
Submission Process The completed form can be submitted to the Social Security Administration in person, by mail, or in some cases, online.
Governing Law SSA-795 is governed by federal law, as it is a form used by the Social Security Administration, a federal agency. There are no state-specific laws governing this form.

Steps to Writing SSA SSA-795

Filling out the SSA-795 form is a necessary step for individuals needing to provide the Social Security Administration (SSA) with specific information. This document allows individuals to make clear statements regarding their benefits or earnings, ensuring their records are accurate and up-to-date. Once the form is submitted, the SSA will review the information provided and make any necessary adjustments to the individual's benefits or records. It is crucial to fill out the form accurately to avoid delays or errors in processing.

  1. Begin by entering your full name, including your first name, middle initial, and last name, in the designated area at the top of the form.
  2. Provide your Social Security Number (SSN) in the space provided. This is crucial for ensuring that your records are accurately matched with your statement.
  3. Fill in your complete address, including street address, city, state, and ZIP code. This information is necessary for any correspondence that may need to be sent to you.
  4. If applicable, enter your phone number where you can be reached. This may be used for clarification or additional information.
  5. In the large section provided for your statement, clearly write or type the information you are reporting or clarifying to the SSA. Be concise but thorough, providing all necessary details and dates.
  6. Check over your statement to ensure it accurately reflects the information you want to convey to the SSA. It’s important that this section is filled out clearly to avoid misunderstandings.
  7. Sign and date the form in the designated area at the bottom. Your signature certifies that the information provided is true and accurate to the best of your knowledge.
  8. If a witness is required or if someone else prepared the form for you, ensure their information is filled out in the appropriate section, including their name, address, and relationship to you.

After completing the SSA-795 form, you should submit it to the local Social Security office or the office specified in the instructions provided to you. The form can often be submitted in person, by mail, or in some cases, online. It is advisable to keep a copy of the form for your records. Following submission, the SSA will process your information, which may involve contacting you for further clarification. This process ensures your Social Security records are accurate and up to date, reflecting your current situation accurately.

Important Details about SSA SSA-795

What is the SSA-795 form used for?

The SSA-795 form is a document utilized by the Social Security Administration (SSA) for individuals to submit any kind of statement or claim that affects their Social Security benefits. This can range from reporting changes in income, marital status, or providing clarification on previously submitted information. It serves as a versatile tool to communicate with the SSA, ensuring one's records are current and accurate.

How can someone obtain an SSA-795 form?

Individuals can obtain an SSA-795 form by downloading it from the official Social Security Administration website. Additionally, one may also visit a local SSA office to pick up a copy. It is made readily available to ensure that individuals have easy access to the means of communicating necessary information with the SSA.

Is there a fee to submit an SSA-795 form?

No, there is no fee required to submit an SSA-795 form to the Social Security Administration. The form is a part of the administration's efforts to ensure that individuals can report information or make claims regarding their Social Security benefits without incurring any costs.

Can the SSA-795 form be submitted online?

As of the last update, the Social Security Administration does not universally accept the SSA-795 form through online submission for all types of statements or reports. However, there are specific instances or updates that the SSA may allow to be reported online. It's recommended to check the official SSA website or contact them directly for the most current information regarding online submission capabilities.

What information is typically required on the SSA-795 form?

The SSA-795 form requires the individual's personal information, including Social Security Number and contact details. Beyond personal identification, the form essentially consists of a statement section where the individual writes the information they wish to report to the SSA. The specificity of the required information will depend on the nature of the statement or claim being made.

How long does it take for a submitted SSA-795 form to be processed?

The processing time for an SSA-795 form can vary depending on the complexity of the information provided and the current workload of the SSA office handling the submission. While there is no standard processing time, it's advisable to allow for several weeks. If confirmation or further action is needed, the SSA will contact the individual directly.

Common mistakes

One common mistake individuals make when filling out the SSA SSA-795 form is not reviewing it for completeness. In their rush to submit the form, they often leave certain sections blank. These omissions can lead to unnecessary delays in the processing of their application because the Social Security Administration (SSA) needs all the requested information to make an accurate determination regarding their request or claim.

Another error arises from not carefully reading the instructions. The form comes with specific guidance on how to fill it out, including which sections may not apply to every applicant. Ignoring these instructions can result in providing irrelevant or incorrect information, which can complicate or even jeopardize the integrity of one's application.

Many people also neglect to provide detailed explanations where required. The SSA SSA-795 form is designed to capture nuanced information about an individual's situation. A lack of detailed responses can hinder the SSA's understanding of the case, leading to potential misinterpretations of an applicant's needs or eligibility.

Another prevalent mistake is using incorrect dates or providing inaccurate information. Dates are crucial for the SSA to establish timelines and verify other information in an application. Wrong dates can significantly confuse the processing of claims, affecting the outcomes adversely.

Applicants often forget to sign the form, a simple yet critical oversight. A signature is essential for the form’s validity; it signifies that the applicant attests to the truthfulness and accuracy of the provided information. An unsigned form is considered incomplete and will not be processed.

A failure to keep a copy of the completed form is another common mistake. Having a record is invaluable for future reference, especially if there are discrepancies or questions about the application later on. It serves as proof of the information submitted to the SSA.

Not using black ink can cause issues with legibility, especially since many forms are scanned and digitized. The SSA specifies the use of black ink for a reason; it ensures that all the details are captured accurately during the scanning process.

Incorrectly assuming that assistance is unnecessary leads many to make avoidable errors. Completing the SSA SSA-795 form can be complex, and seeking guidance from a professional or a trusted guide can significantly decrease the likelihood of mistakes.

Lastly, applicants often underestimate the importance of reporting changes. If circumstances change after submitting the form, it is crucial to inform the SSA. Failing to report changes can result in receiving benefits for which one is no longer eligible, leading to complications or even penalties down the line.

Documents used along the form

When dealing with Social Security and disability claims, applications often require more than just the completion of an SSA-795 form, which is a Statement of Claimant or Other Person. This form is typically used to clarify or provide additional details about an applicant's work history, medical condition, or income. However, to comprehensively evaluate a claim, the Social Security Administration (SSA) usually requests supplementary forms and documentation. Understanding these associated documents can simplify the process for claimants.

  • Application for Social Security Benefits (SSA-1-BK): This form initiates the process of applying for retirement, disability, and spouses' benefits. It collects basic personal and family information.
  • Adult Disability Report (SSA-3368-BK): Essential for disability claims, this document details the applicant's medical condition, work history, and how the disability affects their life.
  • Authorization to Disclose Information to the Social Security Administration (SSA-827): A critical form that allows the SSA to obtain medical, school, and other records necessary to determine eligibility for benefits.
  • Medical Release Form (SSA-827): This form also permits healthcare providers to release the applicant's medical records to the SSA, crucial for supporting disability claims.
  • Child Disability Report (SSA-3820-BK): Similar to the Adult Disability Report but tailored for claims involving children under the age of 18. It collects information about the child's condition and how it impacts their life.
  • Work History Report (SSA-3369-BK): Compiled information on the applicant's employment background over the last 15 years, helping determine how their disability affects their ability to work.
  • Function Report - Adult (SSA-3373-BK): A questionnaire that evaluates how an individual's disability affects their daily activities, both at home and in social settings.
  • Function Report - Child (SSA-3375-BK): Similar to the Adult Function Report but focuses on how a child's disability affects their functioning in daily life and in comparison with children of the same age.

Applying for Social Security benefits, especially on disability grounds, involves gathering and submitting a substantial amount of information. By understanding and preparing the necessary documents in advance, applicants can ensure a smoother application process. Each document plays a vital role in painting a complete picture of the applicant's situation, significantly contributing to the SSA’s decision on their claim. It's crucial for applicants to fill out these forms accurately and provide thorough information to avoid delays or denials of benefits.

Similar forms

The SSA-795 form, used by the Social Security Administration, is akin to IRS Form W-4, which employees use to determine their tax withholdings. Both forms are pivotal for individuals to communicate their financial situations to government entities. The SSA-795 enables individuals to present their verbal statements regarding their Social Security benefits in writing, similar to how the W-4 allows employees to dictate the amount of tax to be withheld from their paychecks based on their financial status and personal allowances. Therefore, each form acts as a critical communication tool between citizens and government programs, impacting their financial operations.

Comparable to the SSA-795 is the VA Form 21-4138, Statement in Support of Claim, used by the Department of Veterans Affairs. Veterans use this form to provide supporting evidence or clarification for their claims, much like individuals use SSA-795 to clarify or provide evidence regarding their Social Security benefits. Both documents serve as official ways for individuals to communicate specific circumstances or details to federal agencies, playing a crucial role in the determination of benefits or claims.

Form I-9, Employment Eligibility Verification, shares similarities with SSA-795 in that both are federally mandated forms that capture essential personal information for verification purposes. Whereas the SSA-795 collects information to assist with Social Security benefits processing, the I-9 confirms an employee's legal right to work in the United States. Each form is critical in ensuring compliance with federal regulations, safeguarding individuals' rights and benefits.

The Advance Directive form is another document with similarities to the SSA-795. While the SSA-795 is used to make statements about one's Social Security benefits, the Advance Directive is used to make known one's wishes regarding medical treatment and end-of-life care. Both forms enable individuals to express their preferences in writing, ensuring their wishes are understood and respected by relevant authorities or organizations.

Similarly, the Health Insurance Claim Form (CMS-1500) used by healthcare providers to bill Medicare and Medicaid has purposes akin to the SSA-795. It facilitates communication between healthcare providers and government insurance programs about provided services, mirroring how the SSA-795 allows for the communication of information between individuals and the SSA. Both forms are crucial for the accurate processing of claims or benefits.

The HUD-1 Settlement Statement, used in real estate transactions, albeit for a different sector, parallels the SSA-795 in its role of detailing transactions in writing. The HUD-1 outlines the final financial terms and conditions of a real estate transaction, while the SSA-795 details statements pertaining to a person's Social Security record. Each document ensures clarity and transparency between parties in financial dealings.

FAFSA (Free Application for Federal Student Aid) is another form bearing resemblance to the SSA-795. FAFSA is essential for students to obtain federal financial aid for education, requiring detailed personal and financial information, similar to the information conveyed through the SSA-795 for Social Security purposes. Both forms are gateways to obtaining financial benefits, contingent on the accurate and thorough presentation of one's financial situation.

The Worker's Compensation Claim Form, like the SSA-795, is designed for individuals to report incidents and provide information crucial for receiving benefits. While the Worker's Compensation form is specific to workplace injuries, the SSA-795 is broader in scope, focusing on aspects related to Social Security benefits. Nonetheless, both serve as vital tools for individuals to communicate necessary information to obtain financial support during times of need.

Last, the Power of Attorney (POA) form shares a fundamental similarity with the SSA-795 in empowering representation. The POA grants an individual the authority to act on another's behalf in legal or financial matters, whereas the SSA-795 allows individuals to submit statements or information that affect their Social Security benefits. Both documents are integral in ensuring that an individual's choices and information are accurately represented and considered by others.

Dos and Don'ts

When filling out the SSA SSA-795 form, individuals must pay close attention to the details and procedures involved to ensure accurate and efficient processing of their information. Below are key guidelines that one should follow, as well as common pitfalls to avoid.

  • Do ensure all information provided is accurate and current. Double-check personal details such as your social security number and contact information for errors to prevent processing delays.

  • Do use black ink when filling out the form by hand. This enhances legibility and ensures that all entries are clearly readable.

  • Do provide thorough and detailed responses when explaining certain items or circumstances. The clarity of provided information can significantly impact the outcome.

  • Do review the entire form before submission to ensure all required fields are completed. Missing information can lead to unnecessary setbacks.

  • Do sign and date the form where indicated. An unsigned form is considered incomplete and will not be processed.

  • Don't leave sections blank unless instructed. If a section does not apply, it is better to note that it is not applicable than to leave it empty.

  • Don't use correction fluid or tape. Mistakes should be neatly crossed out, and the correct information should be clearly written next to it.

  • Don't submit the form without reviewing it for completeness and accuracy. Taking the time to verify can save time in the long run.

  • Don't hesitate to ask for assistance if you are unsure about how to fill out any part of the form. It's better to seek clarification than to submit incorrect or incomplete information.

Misconceptions

The Social Security Administration (SSA) SSA-795 form is an official document used for various purposes, such as correcting earnings records, providing third-party statements supporting disability claims, or clarifying other Social Security-related information. However, several misconceptions surround its usage and importance. Let's debunk four common myths about the SSA-795 form.

  • Myth 1: The SSA-795 form is only for reporting earnings. While correcting or reporting earnings is a common use, the SSA-795 form's versatility extends much further. Individuals can use it to provide critical, clarifying information for disability claims, to update personal details, or to submit any statement affecting their benefits or eligibility. This flexibility makes it an essential tool for various interactions with the SSA.

  • Myth 2: You can only submit the SSA-795 form in person. It's a common belief that this form must be submitted through a face-to-face meeting at a Social Security office. However, the SSA has made strides in increasing accessibility, allowing for submissions via mail and, in some circumstances, online platforms. This adaptability ensures individuals can provide necessary information without the need for an in-person visit, although confirming the best submission method for your specific situation with the SSA is always a good practice.

  • Myth 3: Filling out the SSA-795 form is complicated. The form itself is quite straightforward, designed to capture written statements or clarifications from the person filling it out. The key is to provide clear, complete, and accurate information. There are ample instructions both on the form and available through the SSA’s website to guide individuals through the process, making it more accessible than many might believe.

  • Myth 4: The SSA-795 form is unnecessary if you've already provided information to the SSA. Even if you've previously supplied information to the SSA, circumstances or policies may require an updated statement or additional details. The SSA-795 form offers a formal way to present this information, ensuring it is recorded accurately in your Social Security records. This can be particularly important for complex cases or when verifying the information that influences benefit decisions.

Understanding the true nature of the SSA-795 form and its uses can significantly ease the process of interacting with the Social Security Administration, ensuring individuals can effectively manage their benefits and other related needs.

Key takeaways

The Social Security Administration's (SSA) SSA-795 form is a versatile document used for a variety of purposes, ranging from offering clarifications to providing additional information that supports a Social Security claim or application. Here are key takeaways for effectively filling out and utilizing this form:

  • Carefully read the instructions: Before filling out the form, it's crucial to review the instructions provided by the SSA to ensure that the information you provide is accurate and relevant to your situation.
  • Complete all required sections: Ensure that every section of the form that applies to your situation is filled out. Incomplete forms may lead to delays in the processing of your application or claim.
  • Use clear and concise language: When providing explanations or additional information, use straightforward language. Avoid technical jargon or unnecessary embellishments that could confuse the issue at hand.
  • Be precise: Offer specific details when explaining your situation or providing additional information. Vague statements can lead to misunderstandings or requests for further clarification.
  • Include relevant dates: When providing historical information, always include relevant dates. This helps the SSA verify your claims and understand the timeline of events.
  • Reference supporting documents: If you're submitting additional documentation along with the SSA-795 form, make sure to reference these documents in your explanations or statements, pointing out how they support your claims or application.
  • Sign and date the form: Your signature certifies that the information you've provided is true and complete to the best of your knowledge. Remember to also date the form at the time of signing.
  • Keep a copy for your records: After submitting the form and any supporting documents to the SSA, retain copies for your personal records. These can be critical if there are questions or issues with your application or claim in the future.

By following these guidelines, individuals can ensure that the SSA receives all necessary information in a clear and organized manner, which can facilitate the processing of their application or claim. Remember, thoroughness and clarity are key when filling out the SSA-795 form.

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