SSA-795
Statement Of Claimant Or Other Persons
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the SSA-795
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NAME OF WAGE EARNER, SELF-EMPLOYED PERSON, OR SSI CLAIMANT SOCIAL SECURITY NUMBER
- -
NAME OF PERSON MAKING STATEMENT
(If other than above wage earner,
self-employed person, or SSI claimant)
RELATIONSHIP TO WAGE EARNER, SELF EMPLOYED
PERSON, OR SSI CLAIMANT
Understanding that this statement is for the use of the Social Security Administration, I
hereby certify that -
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