SSA-795: Statement of Claimant or Other Person
Form SSA-795 is Social Security's general-purpose signed statement. When SSA needs facts in writing that no other form captures, a claimant, family member, employer, or other person puts them on an SSA-795 under penalty of perjury.
This is the genuine SSA PDF, unmodified. Source: SSA official page.
What is SSA-795?
SSA-795, Statement of Claimant or Other Person, is a mostly blank form used to record a written statement for a Social Security matter. SSA staff often ask for one to document things like living arrangements for SSI, an explanation of work activity or self-employment, why an application or appeal was filed late, household income details, or corrections to information given earlier.
What makes the form significant is the penalty clause: the signer declares under penalty of perjury that the statement is true. That gives the statement evidentiary weight in the claim file, so it should be accurate, specific, and limited to facts the signer actually knows. Anyone with relevant knowledge can complete one, not just the claimant.
Who files SSA-795?
- Claimants asked by SSA to explain or document something in writing, such as work activity or living arrangements
- People giving a good-cause explanation for a late filing or a missed deadline
- Family members, employers, or others providing firsthand information about a claimant's situation
- Representative payees or helpers documenting facts relevant to a beneficiary's record
How to fill out SSA-795
- Enter the name and Social Security number of the person the statement concerns, and your own name if you are writing about someone else.
- Write the statement in the space provided, sticking to specific facts, dates, and amounts; continue on a second form or attached page if needed.
- Read the penalty clause, then sign and date the form, including your address and phone number.
- Attach any documents that support what you wrote, such as pay stubs or letters.
- Give the statement to the SSA representative who requested it, or send it to your local Social Security office with your claim or appeal.
Quick fill SSA-795 on this page
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Frequently asked questions
When would SSA ask me for an SSA-795?
Whenever a fact needs to be in writing and no dedicated form exists for it. Common examples include explaining a gap in work history, describing who lives in your household for SSI, clarifying a discrepancy in your file, or stating why you filed an appeal late.
Does the statement have to be in my own words?
It should reflect your own knowledge, and it is fine for an SSA employee or a helper to write it down for you. Read it carefully before signing, because your signature certifies under penalty of perjury that the contents are true.