Waiver of Right to Appear--Disability Hearing

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB NO.0960-0534

TOE 710

WAIVER OF RIGHT TO APPEAR

- DISABILITY HEARING

(DONOT WRITE IN THIS SPACE)

Privacy A d Notice: The Social Saurity Ad~ninisirationis authorized to collecl the infonnation on this fonn unda
sections 2OS(a), 1631(cMl)(A) and tB), and 1872 of the Social Security Act, as aincndcd (42 U.S.C.
405, 1383 and
1395ii). Giving us the informalinn on this tbrm is voluntary. However, if you do not impnnd, wc will be unable to act cm
your reque5t to waivc your righ~lo a p p m at a disability hearing. The Social Security Adminisiration will use the
infonniltion on this fonn to fully c v a l u r your claim for disability benefits. We may mutincly give out ihe infonnation on
this hnn without your coment if:
I. A Fdcral law quires thar w e give out this information:
2 . Your Congrcwmanor the Prcsidcmt's O f f ~ needs
e
this informatiun to answer quwtions you ask them:
3 , So~ncnncnc& this information to do s~isticalmearch or audit rcpna f11ru~rrlatcd to thc Social Sccurity

pmgnrlns. ora

4,Thu Dcprtmcnt of Justice w x k I&

infomalion to reprcscnl tk Fdernl Govcrn~ncntin a coun suit related to

SSA edmi~iisttredprograms.
Explanations about tlicsz and olher reasons why infomalion you pruvidc us nay be used or given out are available in
Social Srcuriiy Ofticti. Il'you wan1 to lmrn ~ m a h o u this.
l wmct any Social Sccurity Ofice.

NAME OF CLAIMANT

NAME OF WAGE EARNER OR SELF-EMPLOYED

LSOClAL SECURITY NUMBER

-

-

(COMPLETE ONLY IN SUPPLEMENTAL SECURITY INCOME CASE)
OClAL SECURITY NUMBER
NAME OF SPOUSE

TYPE
OF
BENEFIT

I

1

-

1

I

!

DlSABlLllY

WORKER

-

a CHILD

I

SSI

DISABILITY

0

BLIND

CHILD

NAME OF REPRESENTATIVE. IF ANY

TELEPHONE NUMBER (INCLUDE

REPRESENTATIVE'S ADDRESS

AREA CODE)
1

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. Iunderstand 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 representationat
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)

,IGN
HERE

DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER (INCLUDE
AREA CODE)

b

MAILING ADDRESS (NUMBER AND STREET. APT. NO., P.O. BOX, OR RURAL ROUTE)
CITY AND STATE

ZIP CODE

-

Witnesses are required ONL Y if this form has been signed by mark (XI above. If signed by mark (XI, two witnesses lo the
signing who know the person requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE}

ADORESS INUMBER AND STREET, CITY, STATE. ZIP CODE1
1

Form SSA-77344 (7-88) ef (12-2004)

4 copies: Claims File. DHU. Claimant, O#er

-

Papemork Reduction Act Statement This information collection meets

Thefollowing revised PRA Statement will be inserted into theform at its
at& scheduled reprinting:
Papemork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 8 3 507, 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 3
minutes to read the instructions, gather the facts, and answer the questions, SEND OR
BRING 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 1-800-772-12 t 3. You may send commenh
on our time estimate above to: SW , 640I Security Blvd, Baltimore, MD 21235-6401.
Send&o cornmen& r e f i g to our time estirna fo this uddress, not the completed
form