Form HA-85 (09-2021)
Discontinue Prior Editions
Social Security Administration
REQUEST TO WITHDRAW A HEARING REQUEST
Page 1 of 3
OMB No. 0960-0710
Important Notice - This is a request to withdraw your hearing request. The judge will consider
this request and decide if dismissing your hearing request is appropriate. If we deny your
request, the hearing process will go on as if you had not filed this form. If we approve this
request, the hearing process will stop. We will send you a dismissal notice and we will not
process your case. The last determination in your case will stay in effect. If you change your
mind, you must ask the judge to cancel this request to withdraw within 60 days after you get
the dismissal notice. You must give a good reason why the dismissal was wrong. You may
also file an appeal with the Appeals Council (AC) within 60 days after you get the dismissal
notice. Even if you do not ask the judge to cancel your request, and do not file an appeal, the
AC may set aside the dismissal of your hearing request. This would occur within 60 days
after we mail the dismissal notice to you.
Do not write in this space
Claimant Name
Print Your Name (First name, middle initial, last name)
Claimant SSN
Date of Hearing Request
Wage Earner Name, If Different (or, if applicable, name of surviving eligible spouse or other individual
eligible to receive benefits due a deceased claimant)
Claimant Claim Number,
if Different
Type of Claim(s) Benefit Applied For
I wish to withdraw my hearing request. My request is voluntary. I understand the effects of this request. Namely, a judge may
dismiss my hearing request. If the judge does, the last determination in my case will stay in effect, unless the dismissal is set
aside. This may result in the potential loss of benefits. I understand that I have 60 days from when I get the dismissal notice to
cancel my request or file an appeal with the Appeals Council. My decision affects no other potential parties to my knowledge. I
understand that all items relating to my claim will be part of SSA's records.
Give reason for withdrawal. (If you need more space, use the second page of the form.)
Continued on page 2
Signature (First name, middle initial, last name) (Write in ink)
Date (MM/DD/YYYY)
Telephone Number (include area code)
Mailing Address (Number and Street, Apartment Number, P.O. Box, or Rural Route)
City and State ZIP Code Enter Name of County (if any) in which you now live
Witnesses are required ONLY if this request has been signed by a mark (X) above. If signed by a mark (x), two witnesses to the
signing, who know the person making the request, must sign below. Both witnesses must give their full address.
1. Signature of Witness
Address (Number and Street, City, State, ZIP Code)
2. Signature of Witness
Address (Number and Street, City, State, ZIP Code)
