I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.
SIGNATURE OF PERSON MAKING STATEMENT
Signature (First name, middle initial, last name) (Write in ink) Date (Month, day, year)
Telephone Number (Include Area Code )
Mailing Address (Number and street, Apt. No.,P.O.Box, Rural Route)
City and State ZIP Code
Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the individual must sign below, giving their full addresses.
1. Signature of Witness
Address (Number and street, City, State, and ZIP Code)
2. Signature of Witness
Address (Number and street, City, State, and ZIP Code)
Privacy Act Statement
Collection and Use of Personal Information
Section 205a of the Social Security Act (42 U.S.C. § 405a), as amended, authorizes us to collect the information on this
form. We will use this information to determine your potential eligibility for benefit payments.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the requested information may
affect our ability to evaluate the decision on your claim.
We rarely use the information you provide for any purpose other than for determining entitlement to benefit payments.
However, we may use the information you give us for the administration and integrity of our programs. We may also
disclose information to another person or to another agency in accordance with approved routine uses, which include, but
are not limited to, the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the Government
Accountability Office and the Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and
local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records
with records kept by other Federal, State, or local government agencies. We use the information from these programs to
establish or verify a person’s eligibility for federally-funded or administered benefit programs and for repayment or
incorrect payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notices, 60-0089,
Claims Folders Systems. This notice and additional information regarding our programs and systems are available online
at www.socialsecurity.gov
or at your local Social Security office.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. §3507, as
amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we
display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read
the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or
you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate
above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.
Form SSA-795 (09-2015) ef (09-2015)
