Fillable Ssa-773-u4 Waiver of Right to Appear - Disability Hearing

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Ssa-773-u4 Waiver of Right to Appear - Disability Hearing

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Form SSA-773-U4 (08-2015) ef (08-2015)
SOCIAL SECURITY ADMINISTRATION
WAIVER OF RIGHT TO APPEAR - DISABILITY HEARING
FORM APPROVED
OMB NO. 0960-0534
TOE 710
(DO NOT WRITE IN THIS SPACE)
NAME OF CLAIMANT
NAME OF WAGE EARNER OR SELF-EMPLOYED SOCIAL SECURITY NUMBER
(COMPLETE ONLY IN SUPPLEMENTAL SECURITY INCOME CASE)
SOCIAL SECURITY NUMBERNAME OF SPOUSE
TYPE
OF
BENEFIT
DISABILITY SSI
NAME OF REPRESENTATIVE, IF ANY
REPRESENTATIVE'S ADDRESS TELEPHONE NUMBER (INCLUDE
AREA CODE)
I have been advised of my right to have a disability hearing. I understand that a hearing will give me an
opportunity to present witnesses and explain in detail to the disability hearing officer, who will decide my case,
the reasons why my disability benefits should not end. I understand that this opportunity to be seen and heard
could be effective in explaining the facts in my case, since the disability hearing officer would give me an
opportunity to present and question witnesses and explain how my impairments prevent me from working and
restrict my activities. I have been given an explanation of my right to representation, including representation
at a hearing by an attorney or other person of my choice.
Although the above has been explained to me, I do not want to appear at a disability hearing, or have
someone represent me at a disability hearing. I prefer to have the disability hearing officer decide my case on
the evidence of record plus any evidence which I may submit or which may be obtained by the Social Security
Administration. I have been advised that if I change my mind, I can request a hearing prior to the writing of a
decision in my case. In this event, I can make the request with any Social Security office.
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER (INCLUDE
AREA CODE)
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,ZIP
CODE)
ADDRESS (NUMBER AND STREET,CITY,STATE,ZIP
CODE
)
2. SIGNATURE OF WITNESS
4 copies: Claims File, DHU, Claimant, Other
WORKER
WIDOW/
WIDOWER
CHILD DISABILITY BLIND CHILD
- 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 15 minutes to read the instructions, gather the facts, and
answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is 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.
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and (b) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you provide to
acknowledge your waiver of right to appear at a disability hearing.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on your waiver request.
We rarely use the information you supply us for any purpose other than to make a determination
regarding waiver eligibility. 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 complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices 60-0089, entitled Claims Folders
Systems and 60-0005, entitled Administrative Law Judge Working File on Claimant Cases.
Additional information about these and other system of records notices and our programs are
available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs 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.
Paperwork Reduction Act Statement
Form SSA-773-U4 (08-2015) ef (08-2015)
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Ssa-773-u4 Waiver of Right to Appear - Disability Hearing

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Completed 17 November 2019

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