Form HA-504 Acknowledgement of Receipt (Notice of Hearing)

Form Approved
OMB NO. 0960-0671

ACKNOWLEDGMENT OF RECEIPT (NOTICE OF HEARING)
(Complete this form and return it at once in the envelope provided. No postage is necessary.)
CLAIMANT

SOCIAL SECURITY NUMBER

WAGE EARNER

ADMINISTRATIVE LAW JUDGE

HEARING SCHEDULED

HEARING OFFICE

-

-

LOCATION OF HEARING

(Check only one)

I will be present at the time and place shown on the Notice of Hearing. If an emergency arises after I mail this
form and I cannot be present, I will immediately notify you at the telephone number shown on the Notice of Hearing.
I do not want to appear at my hearing by video teleconference. Please reschedule my hearing so that I may
appear before you in person.
I cannot be present at the time and place shown on the Notice of Hearing. I request that you reschedule my
hearing because:

NOTE: YOUR REQUEST FOR HEARING MAY BE DISMISSED IF YOU DO NOT ATTEND THE HEARING AND CANNOT GIVE A GOOD REASON
FOR NOT ATTENDING. THE TIME OR PLACE OF THE HEARING WILL BE CHANGED IF YOU HAVE A GOOD REASON FOR YOUR REQUEST.
SIGNATURE

DATE

AREA CODE AND TELEPHONE NUMBER

(

)

-

I have recently moved. My new address is:

Privacy Act Notice: The Social Security Act (sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (c), as appropriate) authorizes the
collection of information on this form. We need the information to continue processing your claim. You do not have to give it, but if you do not you
may not receive benefits under the Social Security Act. We may give out the information on this form without your written consent if 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; to the President or a
Congressman inquiring on your behalf; to an independent party who needs statistical information for a research paper or audit report on a Social
Security 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 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.
See Revised PRA, Attached

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 1 minute to read the instructions, gather the facts, and answer the questions. You may send comments on
our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.

Form HA-504 (09-2003) ef (10-2004)

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 1 minute
to read the instructions, gather the facts, and answer the questions. 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.