Form HA-4608 Waiver of Right to Personal Appearance Before an Adminis

Social Security Administration/Office of Hearings and Appeals

Form Approved
OMB No. 0960-0284

WAIVER OF YOUR RIGHT TO PERSONAL APPEARANCE BEFORE AN ADMINISTRATIVE LAW JUDGE
Claimant

Wage Earner (Leave blank if same as claimant)

Social Security Claim Number

NOTE: Please read the PRIVACY ACT statement on reverse and the statements below. Then, print, write, or
type your response to the statements in the space provided below. If you need more space, attach a separate
page to this form.
• I have been advised of my right to appear in person before an Administrative Law Judge. I understand that

my personal appearance before an Administrative Law Judge would provide me with the opportunity to
present written evidence, my testimony, and the testimony of other witnesses. I understand that this
opportunity to be seen and heard could be helpful to the Administrative Law Judge in making a decision.

• Although my right to a personal appearance before an Administrative Law Judge has been explained to me,

I do not want to appear in person. I want to have my case decided on the written evidence. The reason I do
not want to appear in person at a hearing is:

• I understand that if I do not appear before an Administrative Law Judge, I still have the right to present a

written summary of my case, or to enter written statements about the facts and law material to my case in
the record.

• If I change my mind and decide to request a personal appearance before the Administrative Law Judge, I

understand that I should make this request to the Hearing Office before the decision of the Administrative
Law Judge is mailed to me.

• I understand that I have a right to be represented and that if I need representation, the Social Security

office or hearing office can give me a list of legal referral and service organizations to assist me in locating
a representative.

SIGNATURE OF CLAIMANT (OR AUTHORIZED REPRESENTATIVE)

Form HA-4608 (3-2003) EF (7-2003)
Prior Edition May Be Used Until Exhausted

DATE

PRIVACY ACT NOTICE
The Social Security Act (sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1), as
appropriate) authorizes the collection of information on this form. We will use the information you
provide to determine if your claim may be decided without an oral hearing. You do not have to give
it, but if you do not you may not receive benefits under the Social Security Act. We need to get
more information to decide if you are eligible for benefits or if a Federal law requires us to do so.
Specifically, we may provide information to another Federal, State, or local government agency
which is deciding your eligibility for a government benefit or program; or to the Department of
Justice to represent the Federal Government in a court suit related to a program administered by
the Social Security Administration. We explain, in the Federal Register, these and other reasons
why we may use or give out information about you. If you would like more information, get in
touch with any Social Security office.
We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government agencies.
Many agencies may use matching programs to find or prove that a person qualifies for benefits paid
by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given
out are available in Social Security offices. If you want to learn more about this, contact any Social
Security office.

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 2 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. You may send comments on our time estimate above
to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001. Send only comments relating to our
time estimate to this address, not the completed form.

Form HA-4608 (3-2003) EF (7-2003)