Form Approved
OMB No. 0960-0045
DEPARTMENT OF
HEALTH AND HUMAN SERVICES
SOCIAL SECURITY ADMINISTRATION
STATEMENT OF CLAIMANT OR OTHER PERSON
NAME OF WAGE EARNER, SELF-EMPLOYED PERSON, OR SSI CLAIMANT
Sam Manubag
NAME OF PERSON MAKING STATEMENT (If other than above wage earner, self-employed
person, or SSI claimant)
SOCIAL SECURITY NUMBER
575-92-2303
RELATIONSHIP TO WAGE EARNER, SELF-EMPLOYED
PERSON, OR SSI CLAIMANT
Father
Sam Manubag
Understanding that this statement is for the use of the Social Security Administration, I hereby
certify that I would like to try to explain that I am the father of Alvan Manubag who is collecting my benefit
,it is hard for me to explain everything and I was a collecting Alvan Manubag benefits on 2015 I was
interview by Alex Eusebio,a representative of SSA and I was using the bank account name me and my son.I
was making a house to live me and my son here in the Philippines and that I was using the money to build a
house and by some service transportation and Alex Eusebio decide to transfer the beneficiary to the name
of grand mother of my son and i was sing-ing on 2015 but I was using the money like I said to build a house
and use transportation.In 2016,I had no contact with the grandmother since the benefit transferred to her
name and the grandmother on me 6 months benefits of my son,right now I am here in the Philippines.The
only time to see my son if I go to his school on launch time and I would try to call my son must of a time
doesnt answer my call and then grandmother of my son suppose to lend when I am here in the Philippines
on the week ends.And I have no further contact with grandmother name Marilou Canaya,I had emotional
stress about seeing to my son.I need help for SSA about my sons situation he doesnt want to come on me
or come in our house.What I am concern to be a father the future of my son about going school and all
expenses on his benefit.I dont want to happened when he comes 18 years old and I am the one who is
responsible in school when he comes in 19 years old.What i am concerned of his future and I was
supporting him since birth,I want to be a father controlling his benefit money that controlling every month if
you trust me again or give me some explanation on how to used there money being controlled every
month.Right now,I am not working and I am collecting disability that is why I cam concerned about when he
comes 19 and his benefit will ended.Each hard for me to explain about what I am feel I am a sick person
and depending on medications and I think I want not going want futher explanation hopely you will
understand what is a father concern right now I am still building my house here in the Philippines and also
going back to U.S for seeing my doctors because I have pained and I dont want get more stress about my
sons situation.And being teaching them not see me and answer my call.Hopely you can answer me to
consult my problem on this situation and i am glad to answer me back and appreciate to answer me
back.Thank you
Form SSA-795 (2-76)
Page 1 of 2
Form Approved
OMB No. 0960-0045
DEPARTMENT OF
HEALTH AND HUMAN SERVICES
SOCIAL SECURITY ADMINISTRATION
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)
Date (Month, day, year)
SIGN
HERE
Telephone Number (Include Area Code)
09174003641
Mailing Address (Number and Street, Apt. No., P.O. Box, Rural Route)
Bahay,Sibonga,Cebu
City and State
ZIP Code
Cebu
6020
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 and street, City, State, and ZIP Code)
Address (Number and street, City, State, and ZIP Code)
Bahay,Sibonga,Cebu
Bahay,Sibonga,Cebu
Form SSA-795 (2-76)
Page 2 of 2
