Form SSA-789 (01-2019) UF Page 2 of 2
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading
statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison,
or may face other penalties, or both.
EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH
CLAIMANT SIGNATURE
STREET ADDRESS
CITY STATE ZIP CODE
TELEPHONE NUMBER DATE
SIGNATURE OR NAME OF CLAIMANT'S REPRESENTATIVE
REPRESENTATIVE'S ADDRESS
CITY STATE ZIP CODE
TELEPHONE NUMBER DATE
Witnesses are required ONLY if this form has been signed by mark (X). If signed by mark (X), two witnesses to the
signing who know the person requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
ADDRESS (Number and Street, City, State, and ZIP Code)
2. SIGNATURE OF WITNESS
ADDRESS (Number and Street, City, State, and ZIP Code)
Privacy Act Statement
Collection and Use of Personal Information
Sections 205 (a) and (b), and 1631 (c)(1)(A) and (B) of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from
reconsidering a determination on your claim.
We will use the information to reconsider your eligibility for disability benefits. We may also share your information for the
following purposes, called routine uses:
• To third party contacts where necessary to establish or verify information provided by representative payees or payee
applicants; and,
• To third party contacts (including private collection agencies under contract with us) for the purpose of their assisting us in
recovering overpayments.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0009, entitled Hearings and
Appeals Case Control System, as published in the Federal Register (FR) on October 13, 1982, at 47 FR 45589; 60-0010, entitled
Hearing Office Tracking System of Claimant Cases, as published in the FR on January 11, 2006 at 71 FR 1806; and 60-0089,
entitled Claims Folders Systems, as published in the FR on April 1, 2003, at 68 FR 15784. Additional information and a full listing
of all our SORNs are available on our website at www.ssa.gov/privacy
.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 13 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social
Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U.S. Government
agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may
send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.
