Social Security Administration (SSA) Edition Form SSA-795 (06-2022) UF (OMB No. 0960-0045); discontinue prior editions 2 pages

Form SSA-795 — Statement of Claimant or Other Person

Social Security's blank-page form for putting facts about a claim in writing, under penalty of perjury.

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Form SSA-795 · Statement of Claimant or Other Person
The official Social Security Administration (SSA) form, edition Form SSA-795 (06-2022) UF (OMB No. 0960-0045); discontinue prior editions — blank
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Form SSA-795 (2022) Statement of Claimant or Other Person — page 1 of 2
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Form SSA-795 (2022) Statement of Claimant or Other Person — page 2 of 2
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Fill this form online Blank PDF from Social Security Administration (SSA)

What is Form SSA-795?

Form SSA-795 is a general-purpose statement for the Social Security Administration. It has room for the name and Social Security number of the wage earner, self-employed person or SSI claimant, the name and relationship of the person making the statement if it's someone else, and then a full page that begins 'Understanding that this statement is for the use of the Social Security Administration, I hereby certify that -'.

The person making the statement signs it under penalty of perjury, declaring that it's true and correct to the best of their knowledge, and acknowledging that knowingly giving a false statement about a material fact is a crime. If they sign by mark (X), two witnesses who know them sign and give their addresses.

FileIt pre-fills the claimant's name from your vault, checks that the statement fits the page, and prints it onto SSA's own PDF (06-2022 edition), accented names included. It saves the finished form in the person's vault folder. The signature line says to write in ink, so you print it, sign it, and give it to Social Security yourself.

Who writes it
The claimant, or another person who knows the facts, such as a relative, neighbor or employer.
Pages
2: the statement, then the signature, address and witnesses.
Signature
In ink, under penalty of perjury; two witnesses only if signed by mark (X).
Address
The form prints none; it goes to the Social Security office handling the claim.
Edition
Form SSA-795 (06-2022) UF, OMB No. 0960-0045; discontinue prior editions

Who needs to fill out Form SSA-795?

  • Claimants that Social Security has asked to explain something in writing.
  • Relatives, neighbors, landlords or employers asked to confirm facts about someone's claim.
  • SSI claimants and recipients explaining living arrangements, support or other circumstances.

When to use Form SSA-795

  • When Social Security asks for a written, signed statement about a fact in a claim.
  • When you want to put your own account of a fact on record for a Social Security claim.
  • For a release of records use Form SSA-3288, and for a medical release Form SSA-827.

What you need before you start

  • The name and Social Security number of the wage earner, self-employed person or SSI claimant.
  • If someone else is making the statement, their name and relationship to the claimant.
  • The facts to state, with dates, places and amounts where they matter.
  • The signer's mailing address, city, state, ZIP code and phone number.

What’s on Form SSA-795

The 2022 edition has 2 pages. FileIt asks for it in 4 parts:

  1. Whose claim, and who is making the statementPerson making the statement
  2. StatementPerson making the statement
  3. Signature of person making statementPerson making the statement
  4. Witnesses (only if signed by mark)Person making the statement

How to fill out Form SSA-795, step by step

1 Whose claim

The name and Social Security number of the wage earner, self-employed person or SSI claimant.

2 Who's making the statement

Only if it's someone other than the claimant: their name and relationship.

3 The statement

After 'I hereby certify that -', write the facts. FileIt warns you if it won't fit on the page.

4 Signature and contact details

Sign in ink, date it, and add a phone number and mailing address. Witnesses sign only if the statement is signed by mark.

Common mistakes to avoid

  • Leaving out the claimant's Social Security number, so SSA can't match the statement.
  • Writing opinions or second-hand information instead of the facts you know.
  • Forgetting to give your name and relationship when you're not the claimant.
  • Signing in pencil or typing the signature: the form says to write in ink.

After you fill it out

Print the form and sign it in ink.

Give or send it to the Social Security office handling the claim, with any documents it refers to.

Keep a copy. FileIt files the PDF in the person's vault folder.

Fill out Form SSA-795 online with FileIt

  1. Pick the person. Choose someone from People and FileIt fills in their name, date of birth, address and other details it already knows.
  2. Answer plain-language questions. One part of the form at a time, with the official help text beside each question — 13 fields in all. Your answers save as you go.
  3. Check the live preview. Watch your answers land on the real Social Security Administration (SSA) form, and let FileIt do any worksheet arithmetic.
  4. Generate the official PDF. FileIt prints your answers into the agency’s own PDF and files it in that person’s folder in your vault.

FileIt fills the form — it never files or submits anything for you. Deliver the finished form to whoever asked for it, the way the form’s instructions say.

Start Form SSA-795 now — it’s free

Form SSA-795: frequently asked questions

What is Form SSA-795 used for?

It's a general statement form for giving Social Security information about a claim in writing, signed under penalty of perjury, by the claimant or by another person.

Can someone else fill it out for a claimant?

Yes. The form has a box for the name of the person making the statement, if other than the claimant, and their relationship.

Do I need witnesses?

Only if the statement is signed by mark (X). Then two witnesses who know the person sign and give their full addresses.

Can I sign it electronically?

No. The signature line says to write in ink.

What if I need more space?

The statement box is a full page. FileIt checks your text fits; if it doesn't, shorten it or attach a separate signed sheet.

Official sources

FileIt is not affiliated with or endorsed by Social Security Administration (SSA) or any government. This page explains the form in general terms and is not legal, tax or immigration advice. Always read the official instructions, and check that you are using the edition the recipient accepts. Page last reviewed 2026-10-01.

Fill out Form SSA-795 online