Statement of Claimant or Other Person

Form SSA-795 is SSA's all-purpose sworn statement form, used whenever you or someone who knows you needs to put facts on the record in your own words. In disability cases it is commonly used to clarify an alleged onset date, explain gaps in medical treatment or work attempts that failed because of your condition, describe how symptoms affect daily activities, correct an error in the file, or provide a witness statement from a spouse, relative, former employer, or caregiver. The form carries a penalty clause, meaning statements are made under penalty of perjury, which gives a well-drafted SSA-795 real evidentiary weight. Adjudicators at every level, from DDS examiners to Administrative Law Judges, can consider these statements alongside the medical evidence.

Obtain the SSA-795 from ssa.gov or any field office, or file its online equivalent when available. Identify the claimant's name and Social Security number at the top, then write the statement in clear, factual, first-person language, sticking to what the writer personally knows or observed: dates, events, specific limitations, and concrete examples such as how long you can stand before needing to sit. Avoid conclusions like disabled; describe facts and let the adjudicator conclude. If the statement continues onto additional pages, note that on the form. Sign and date it, and have witnesses sign where required if signing by mark. Submit it to your field office, DDS examiner, or hearing office depending on where your claim is pending, and keep a copy. A representative can help frame statements so they address the legal issues that actually decide claims.