Form HA-L90 Request to Show Cause for Failure to Appear

Form Approved
OMB No. 0960-xxxx
Social Security Administration Office of Disability Adjudication and Review

REQUEST TO SHOW CAUSE FOR FAILURE TO APPEAR
Claimant:

Wage Earner:

Social Security Claim Number

NOTE: Please read the PRIVACY ACT statement on the reverse page and the statements below.
You requested a hearing with an administrative law judge (ALJ). We scheduled a hearing for you for
[hearing date], at [hearing location and time]. You did not come to your hearing or contact us to explain why
you could not attend.
If you still want an ALJ to hold a hearing on your claim, you may explain in writing why you did not come to
your hearing. You may print, write, or type your explanation in the space provided. You may include another
page if you need more space. Attach all supporting documentation. You must send your explanation to us
within 10 days from the date of this notice.
An ALJ will review your explanation. The ALJ will use rules in the Code of Federal Regulations to decide if
your explanation shows that you had a good reason for missing hearing.
• If the ALJ decides that you had a good reason for missing your hearing, we will schedule another
hearing for you.
• If the ALJ decides that you did not have a good reason for missing your hearing, and your
representative also did not come to your hearing, the ALJ may dismiss your request for a hearing.
•
If the ALJ decides that you did not have a good reason for missing your hearing, but your
representative came to your hearing, the ALJ may decide your claim based on the evidence in your
file. (NOTE: THE REFERENCES TO A REPRESENTATIVE WOULD APPEAR ONLY IF THE CLAIMANT IS REPRESENTED.)
I did not come to the hearing because:
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Mail your explanation to: Office of Disability and Review, [hearing office address]. If you have any questions,
you may call [hearing phone number].
SIGNATURE OF CLAIMANT (OR AUTHORIZED REPRESENTATIVE)

HA-L90

DATE

SSA will insert the following revised PRA Statement 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 (OMB) control number. We estimate that it will take
between 10 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.

SSA will insert the following Privacy Act Statement into the form at its next scheduled reprinting:

Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended authorize us to collect this
information. We will use this information to evaluate your reason for failing to appear at your scheduled
hearing.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
requested information may affect our ability to re-evaluate the decision on your claim.
We rarely use the information you supply for any purpose other than for determining problems in Social
Security programs. 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 the Department of Veterans’
Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs as
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 use of routine uses for this information is available in our Systems of Records Notices,
60-0009, Hearings and Appeals Case Control System, and 60-0010, Hearing Office Tracking System of
Claimant Cases. These notices, additional information regarding our programs and systems, are available
on-line at www.socialsecurity.gov or at any local Social Security office.