Supporting Statement for Form SSA-795
Statement of Claimant or Other Person
20 CFR 404.702, 20 CFR 416.570
OMB No. 0960-0045
Introduction/Authoring Laws and Regulations
Section 205(a) of the Social Security Act authorizes the Commissioner of the Social Security Administration (SSA) to regulate and provide rules for the nature and extent of proofs and evidence, and the methods of taking and furnishing proof or evidence, to establish an individual’s eligibility to benefits. Individuals use Form SSA-795 to make signed statements relating to claims for Social Security benefits or Supplemental Security Income (SSI) payments under 20 CFR 404.702 and 416.570 of the Code of Federal Regulations. For example, 20 CFR 416.570 requires individuals’ signed statements before recovery of any overpayment or adjustment of any overpayment under Titles II, VIII, or XVIII. Recipients of any of these programs may elect to have an overpayment withheld from their benefits, and use the SSA‑795 for this purpose.
Description of Collection
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 persons who have knowledge of facts, in connection with claims for Social Security benefits or SSI. The information we request on this form is of sufficient importance that we need both a signed statement and a penalty clause. SSA uses this information to process, in addition to claims for benefits, issues about continuing eligibility, ongoing benefit amounts, use of funds by a representative payee, fraud investigation, and a myriad of other program-related matters. The most typical respondents are applicants for Social Security, SSI, or recipients of these programs. However, respondents also include friends and relatives of the involved parties, coworkers, neighbors, or anyone else in a position to provide information pertinent to the issue(s).
Use of Information Technology to Collect the Information
This agency-initiated form is simply a blank space followed by the penalty clause, allowing the person signing the form to provide any supplemental information desired. SSA also created a remarks screen in MSSICS to collect this information electronically via telephone or personal interview. As the electronic version is a blank MSSICS screen, and most respondents use the paper SSA-795, SSA does not currently track the percentage of users for the screen. In addition, since the collection of this information is agency-initiated, and because this form contains only a blank space and no formal questions, SSA did not make this form available electronically through an Internet application. To make it easier for respondents to complete, SSA created a fillable PDF version of this form, which allows respondents to complete the form prior to printing and sending it to SSA (see Addendum for more details).
Why We Cannot Use Duplicate Information
The nature of the information we collect, and the manner in which we collect it precludes duplication.
Minimizing burden on Small Respondents
The information collection does not affect small businesses or other small entities.
Consequences of Not Collecting Information or Collecting it Less Frequently
SSA uses no other form to collect data similar to what we collect on Form SSA-795. Using the SSA-795, SSA collects information on unresolved issues from claimants or other persons as needed to adjudicate claims, or to resolve post-entitlement issues. If SSA did not collect this information, we could not properly adjudicate claims for benefits or resolve post-entitlement issues. Since SSA only collects the information on an as-needed basis, we cannot collect it less frequently.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on April 7, 2015, at 80 FR 18669, and we received no public comments. SSA published the second Notice on June 23, 2015, at 80 FR 36031. If we receive comments in response to the 30‑day Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.
Payment or Gifts to Respondents
SSA provides no payment or gifts to the respondents.
Assurance of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.
Justification for Sensitive Questions
This information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Approximately 305,500 respondents use Form SSA-795 annually. The estimated average completion time is 15 minutes per form for a total annual burden of 76,375 hours. The total burden reflects burden hours, and SSA did not calculate a separate cost burden.
Annual Cost to the Respondent
There is no known cost burden to the respondents.
Annual Cost to the Federal Government
The annual cost to the Federal Government is approximately $470,470. This estimate is a projection of the costs for printing and distributing the collection instrument, and for collecting the information.
Program Changes or Adjustments to the Information Collection Request
There are no changes in the public reporting burden; however, SSA is implementing a new fillable PDF version of the form to aid respondents. We do not anticipate any change to the burden for the fillable version (see Addendum for more details).
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB exempted SSA from publishing the expiration date for OMB approval on its forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB clearance. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). OMB granted this so that SSA would not have to stop using otherwise useable editions of forms with outdated expiration dates. In addition, we avoid Government waste because we do not have to destroy and reprint stocks of forms.
Exception to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
Collection of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Barnett Roseman |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |