” Form SSA-795 (2-76) Form Approved OMB No. 0960-0045 SOCIAL SECURITY ADMINISTRATION STATEMENT OF CLAIMANT OR OTHER PERSON NAME OF NUMBER HOLDER SOCIAL SECURITY NUMBER NAME OF PERSON MAKING STATEMENT (If not NH) RELATIONSHIP (to NH) Understanding that this statement is for the use of the Social Security Administration, I hereby certify that… ______________________________ rents a room in my home and pays me $______ per month. This is strictly a BUSINESS RELATIONSHIP and we do not consider ourselves as members of the same household. We are related as a parent and child. He\/She does have access to adequate cooking facilities and food storages. If someone other than ______________________________________ rented a room in your house, how much would you charge per month? $___________. If less, why? Please explain below. _________________________________________________________________________________________________ _________________________________________________________________________________________________ ________________________________________________________________________________________________ Is _______________________________ obligated to pay rent as a condition to stay? yes no I know that anyone who makes or causes to be made 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 OF PERSON MAKING STATEMENT Signature (First name, middle initial, last name) (Write in ink) SIGN HERE Date (Month, day, year) Mailing Address (Number and street, Apt. No., P.O. Box, Rural Route) Telephone Numbers (Include Area Code) Home ( ) Work ( ) – 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 2. Signature of Witness Address (Number & street, City, State & ZIP Code) Address (Number & street, City, State & ZIP Code) NAME OF NUMBER HOLDER: SOCIAL SECURITY NUMBER: NAME OF PERSON MAKING STATEMENT If not NH: RELATIONSHIP to NH: rents a room in my home and pays me: per month This is strictly a: rented a room in your house how much: If less why Please explain below: would you charge per month 1: would you charge per month 2: would you charge per month 3: obligated to pay rent as a condition to stay: Date Month day year: Mailing Address Number and street Apt No PO Box Rural Route: City and State: ZIP Code: 1 Signature of Witness: 2 Signature of Witness: Text1: Text323: Address Number street City State ZIP Code: Address Number street City State ZIP Codevqek: ”