Ssa Form 795 - Statement Of Claimant Or Other Person

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Form Approved
Social Security Administration
OMB No. 0960-0045
STATEMENT OF CLAIMANT OR OTHER PERSON
Name of Wage Earner, Self-employed Person, or SSI Claimant
Social Security Number
Name of Person Making Statement (If other than above wage earner,
Relationship to Wage Earner, Self-Employed
self-employed person, or SSI claimant)
Person, or SSI Claimant
Understanding that this statement is for the use of the Social Security Administration, I hereby certify that -
Form SSA-795 (09-2015) ef (09-2015)
Destroy Prior Editions

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