Statement of Claimant or Other Person

ICR 202110-0960-001

OMB: 0960-0045

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2021-11-01
Supplementary Document
2021-10-29
ICR Details
0960-0045 202110-0960-001
Received in OIRA 201803-0960-004
SSA
Statement of Claimant or Other Person
Revision of a currently approved collection   No
Regular 11/02/2021
  Requested Previously Approved
36 Months From Approved 11/30/2021
231,822 305,500
161,575 76,375
0 0

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.

US Code: 42 USC 405 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  86 FR 46897 08/20/2021
86 FR 59262 10/26/2021
No

  Total Request 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 231,822 305,500 0 0 -73,678 0
Annual Time Burden (Hours) 161,575 76,375 0 0 85,200 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
When we last cleared this IC in 2018, the burden was 76,375 hours. However, we are currently reporting a burden of 57,956 hours. This change stems a decrease in the number of responses from 305,500 to 231,822. The figures listed in #12 show the majority of respondents use the paper version of the SSA-795. Due to the COVID-19 pandemic, SSA suspended several workloads requiring Personal Statements, therefore decreasing the number of respondents submitting the paper version of the SSA-795. There is no change to the burden time per response. These figures represent current Management Information data. We also added an additional 30 minutes for travel time for the SSA-795 (paper/in-person interview) version.

$1,339,645
No
    Yes
    Yes
No
No
No
No
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/02/2021


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