Fillable SSA-769-U4 Request for Change in Time/Place of Disability Hearing

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SSA-769-U4 Request for Change in Time/Place of Disability Hearing

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The SSA-769-U4 Request for Change in Time/Place of Disability Hearing form is 2 pages long and contains:

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  • 26 other fields

Country of origin: US
File type: PDF

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Form SSA-769 (09-2017) UF
Discontinue Prior Editions
Social Security Administration
Request for Change in Time/Place of Disability Hearing
Page 1 of 2
OMB No. 0960-0348
Name of Claimant
(DO NOT WRITE IN THIS SPACE)
Name of Wage Earner or Self-Employed Person Social Security Number
Spouse's Name and Social Security Number
(Complete only if Supplemental Security Income Case)
Type of Benefit:
SSIDisability
Worker Widow/Widower Child ChildBlindDisability
Name of Representative, if any
Representative's Address
Telephone Number
(Include area code)
Hearing Currently Scheduled
Request
A different place of hearing (specify place)
A postentitlement of days from
the scheduled hearing date
PlaceTimeDate
The reason for my request is:
Signature (First name, middle initial, last name) (Write in ink)
Date (Month, Day, Year)
Telephone Number
(Include area code)
SIGN
HERE
Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)
City and State ZIP Code
Witnesses are required ONLY if this form has been signed by mark (X) above. 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)
Address (Number and Street, City, State, and ZIP Code)
2. Signature of Witness
Form SSA-769 (09-2017) UF
Discontinue Prior Editions
Social Security Administration
Request for Change in Time/Place of Disability Hearing
Page 1 of 2
OMB No. 0960-0348
Section 205(b) of the Social Security Act, as amended, allows us to collect this information. We will use the
information you provide to attempt to reschedule a disability hearing based on good cause, eligibility, and
availability.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent you from receiving a new time or place of the hearing.
We rarely use the information you supply for any purpose other than what we state above, however, we
may use the information for the administration of our programs, including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity
and improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
A list of when we may share your information with others, called routine uses, is available in our Privacy Act
System of Records Notices, 60-0009, entitled Hearings and Appeals Case Control System, and 60-0010,
entitled Hearing Office Tracking System of Claimant Cases. Additional information about these and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching programs compare
our records with records kept by other Federal, State, or local government agencies. Information from these
matching programs can be used to establish or verify a person’s eligibility for federally funded or
administered benefit programs and for repayment of incorrect payments or delinquent debts under these
programs.
Privacy Act Statement
Collection and Use of Personal Information
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 (OMB) control number.
We estimate that it will take about 20 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.
Paperwork Reduction Act Statement -
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SSA-769-U4 Request for Change in TimePlace of Disability Hearing

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Completed 6 May 2020

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