Statement of Claimant or Other Person

Forms and Documents

Document Name	Status
Form SSA-795 Statement of Claimant or Other Person Form	Modified
Supporting Statement - 0045.docx Supporting Statement A	2015-06-23
Addendum - 0045.docx Supplementary Document	2015-06-23

IC Document Collections

IC ID	Document Title	Status
43690	Statement of Claimant or Other Person Form	Modified

ICR Details

OMB Control No: 0960-0045	ICR Reference No: 201503-0960-010
Status: Historical Active	Previous ICR Reference No: 201205-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Statement of Claimant or Other Person
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/24/2015
	Date Received in OIRA: 07/20/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2018	36 Months From Approved	09/30/2015
Responses	305,500	0	305,500
Time Burden (Hours)	76,375	0	76,375
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the SSA-795 to obtain information from claimants or other persons having knowledge of facts in connection with claims for Social Security benefits or Supplemental Security Income (SSI) payments when there is no standard form to collect the needed information. SSA then uses the information to process claims for benefits or for ongoing issues related to the above programs. The respondents are applicants and recipients, or others having knowledge of facts in connection with claims for Social Security or SSI.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 18669	04/07/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 36031	06/23/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Statement of Claimant or Other Person	SSA-795	Statement of Claimant or Other Person

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	305,500	305,500	0	0	0	0
Annual Time Burden (Hours)	76,375	76,375	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $470,470

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/20/2015

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