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

Form Approved
OMB No. 0960-0284

Social Security Administration/Office of Hearings and Appeals

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 (07-2004)
Prior Edition May Be Used Until Exhausted

DATE

PRIVACY ACT NOTICE
See Revised Privacy Act Statement Attached
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.

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 2 minutes 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 21235-0001. Send only comments relating to our time estimate to this address, not the
completed form.

Form HA-4608 (3-2003) ef (07-2004)

SSA will insert the following revised Privacy Act and PRA Statements into the form at
its next scheduled reprinting:
Certification of Contents of Document(s) or Record(s), HA-4608
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) of the Social Security Act,
as amended, [42 U.S.C. 405 (a), 902, 1383(e)(1)(A), and (B), and 1395ff(b)(1)]
authorize us to collect this information. We will use the information you provide to help
us determine if your claim may be decided without an oral hearing. The information you
furnish on this form is voluntary. However, failure to provide the requested information
may prevent you from receiving benefits under the Social Security Act.
We rarely use the information you provide on this form for any purpose other than for
reasons explained above. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of Social Security programs.
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 payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records
Notices entitled, Quality Review of Hearing/Appellate Process, 60-0213 and Claims
Folder System, 60-0089. The notices, additional information regarding this form and
information regarding our system and programs, are available on-line at
www.socialsecurity.gov or at any local 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 only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.