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Social Security Administration

Fill out Form SSA-795 online

Statement of Claimant or Other Person

Form SSA-795 is a written statement for the Social Security Administration. A wage earner, self-employed person or SSI claimant, or another person, uses it to write a statement for SSA and declares under penalty of perjury that it is true and correct to the best of their knowledge. SSA's own pages point to it, for example, to report a change in work or income while getting Disability or Survivor benefits.

Fill out Form SSA-795Blank form from the SSA

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Edition
(06-2022)
Pages
2
Fillable fields
17
Checked against the SSA
November 8, 2026

GuruPDF is not affiliated with the Social Security Administration. This page explains the form in plain words; it is not legal or tax advice. Always check the official instructions before you file.

Who uses Form SSA-795

  • Wage earners, self-employed people and SSI claimants who need to give SSA a written statement
  • People getting Disability or Survivor benefits who report a change in their work or income
  • Another person who gives SSA a statement about a wage earner, self-employed person or SSI claimant

Before you start

  • The full name and Social Security number of the wage earner, self-employed person or SSI claimant the statement is about
  • If you are someone else: your name and your relationship to that person
  • The facts you want to put in your statement
  • For a change in work or income: a short explanation of the change and the date it happened
  • Your mailing address and telephone number
  • If you will sign with a mark (X): two witnesses who know you

How to fill out Form SSA-795

  1. Page 1, top: the person the statement is about

    Enter the name of the wage earner, self-employed person or SSI claimant, and that person's Social Security number.

  2. Page 1: the person making the statement

    Fill in these two boxes only if the statement is made by someone other than the person named above. Give your name and your relationship to the wage earner, self-employed person or SSI claimant.

  3. Page 1: your statement

    The statement box starts with the words "Understanding that this statement is for the use of the Social Security Administration, I hereby certify that -". Write your statement in the box. When you report a change in work or income, SSA asks for a short explanation of your work status or income change and the date of the change.

  4. Page 2: read the declaration

    The top of page 2 says you declare under penalty of perjury that you have examined the information on the form and on any statements or forms sent with it, and that it is true and correct to the best of your knowledge.

  5. Page 2: signature, date and telephone

    The person making the statement signs in ink with first name, middle initial and last name, and writes the date (month, day, year). Add a telephone number with the area code.

  6. Page 2: mailing address

    Enter the mailing address (number and street, apartment number, P.O. box or rural route), the city and state, and the ZIP code.

  7. Page 2: witnesses, only if signed by mark

    Leave the witness boxes empty unless the statement was signed with a mark (X). In that case, two witnesses to the signing who know the person must sign and give their full addresses (number and street, city, state and ZIP code).

After you fill it out

The form goes to the Social Security Administration. SSA's pages for reporting changes in work or income on Disability or Survivor benefits say you can sign in to SSA's online document upload service, search for the Statement of Claimant or Other Person (SSA-795), complete it, upload any other documents you have and submit it. If you are sending a printed copy, check with SSA where to send it.

Signing: The signature line says to write in ink, and the PDF's own field help says to fill out the form, print it and sign in ink. If the statement is signed with a mark (X), two witnesses who know the person must also sign and give their full addresses.

Watch out for

  • The statement is made under penalty of perjury. The form says anyone who knowingly gives a false statement about a material fact, or causes someone else to do so, commits a crime and may be fined or imprisoned.
  • The form says to discontinue prior editions. This is the 06-2022 edition, the one SSA links to from its forms page.

Questions about Form SSA-795

What is Form SSA-795 used for?

It is a general statement form. You write a statement for SSA's use and certify that it is true. SSA's reporting pages point to it for telling SSA about a change in work or income while getting Disability or Survivor benefits.

Can someone other than the claimant fill it out?

Yes. The form has boxes for the name of the person making the statement, if that is not the wage earner, self-employed person or SSI claimant, and for that person's relationship to them. The person making the statement is the one who signs.

Do I need witnesses?

Only if the statement is signed with a mark (X). Then two witnesses to the signing who know the person must sign on page 2 and give their full addresses.

Do I have to give SSA this information?

The Privacy Act statement on the form says giving the information is voluntary. It also says that leaving out all or part of it may prevent an accurate and timely decision on a claim.

What should I include when I report a change in work or income?

SSA asks for a short explanation of your work status or income change and the date of the change.

Official information

Page text last reviewed November 7, 2026.

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