Form HA-504-OP1 Acknowledgement of Receipt (Notice of Hearing)

Form Approved
OMB NO. 0960-0671

ACKNOWLEDGEMENT 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:

Hearing Office: Office of Hearings and Appeals
ALJ:

Hearing Scheduled: , at
Location of Hearing:

(Check only one item below)
[ ] 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 cannot be present at the time and place shown on the Notice of Hearing. I request that you reschedule my hearing because:

___________________________________________________________________________________________
___________________________________________________________________________________________
(Use space below for additional remarks)
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: ________________ Phone: ______________________

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 be able to 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, Please
we may provide
seeinformation
below 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
for
revised
Privacy
information for a research paper or audit report on a Social Security program;
or the
Department
of Justice to represent the Federal Government in a court suit related to
a program administered by the Social Security Administration.
Act Statement.
Computer Matching Notice: 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.
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 30 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 504-OP1 (09-2003) ef (10-2004)

Acknowledgement of Receipt (Notice of Hearing), Form HA-504
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 702(5), 1631(e)(1)(A) and (B), and 1869(b)(1) and (c) of the Social
Security Act, as amended, [42 U.S.C. 405(a)], [42 U.S.C. 902(5)], [42 U.S.C.
1383(e)(1)(A) and (B)], and [42 U.S.C. 1395ff(b)(1) and (c)] authorize us to collect
this information. We will use the information you provide to continue processing
your claim. The information you provide on this form is voluntary. However, failure
to provide all or part of the requested information could prevent us from making an
accurate and timely decision on your claim.
We rarely use the information you provide on this form for any purpose other than for
the 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, General
Services Administration, National Archives Records Administration, and the
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 and administered benefit
programs for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of
Records Notice entitled, Claims Folder System, 60-0089. This notice, additional
information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at any Social Security
office.