Form Ssa-795 - Social Security Administration Statement Of Claimant Or Other Person

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Social Security Administration
Statement of Claimant or Other Person
Name of Wage Earner or SE Person
Account Number / Social Security Number
Name of Person Making Statement (if other
Relationship to wage earner, self-employed person, or SSI
than above wage earner, self-employed
claimant
person, or SSI claimant)
Statement of person residing in the U.S. for 30 days.
Understanding that this statement is for the use of the Social Security Administration, I hereby certify
that:
1. I have resided in the U.S. for at least one full calendar month:
2. I entered the U.S. on:
3. I departed the U.S. on:
4. I resided at the following address:
5. Phone:
I’m attaching the following as evidence:
Airplane tickets
Visa/ Residency Card
Passport with U.S. entry stamp
Letters from Witnesses
I know that anyone who makes or causes to be a false statement or representation of material fact in an application or for use in
determining a right to payment under the Social Security Act commits a crime punishable under Federal Law and/or State law. I affirm that
all information I have given in this document is true.
Signature
Date (Month, day, year)
Email:
Phone:
Form SSA-795(2-76)

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