Form SSA-789 Request for Reconsideration--Disability Cessation

Form Approved
OMB No. 0960-0349
FOR SOCIAL SECURITY OFFICE USE ONLY

SOCIAL SECURITY ADMINISTRATION

REQUEST FOR RECONSIDERATION -

(DO NOT WRITE IN THIS SPACE)

DISABILITY CESSATION - RIGHT TO APPEAR
(SEE REVERSE SIDE FOR PAPERWORK/PRIVACY ACT NOTICE)
NAME OF CLAIMANT

SOCIAL SECURITY NUMBER

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON (If
different from Claimant)

SOCIAL SECURITY NUMBER

FO Code

SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPLETE ONLY IN
SUPPLEMENTAL SECURITY INCOME CASE)

Benefit Continuation
Foreign Language Notice

TYPE OF
BENEFIT

DISABILITY
WORKER

SSI

WIDOW

CHILD

DISABILITY

CHILD

BLIND

I DO NOT AGREE WITH THE DETERMINATION TO STOP DISABILITY BENEFITS AND I REQUEST RECONSIDERATION. My
reasons are (reasons should relate to the basis for stopping disability benefits and be as specific as possible):
NOTE: If the notice of the determination on your claim is dated more than 65 days ago, include your reason for not making this
request earlier. Include the date on which you received the notice.

I AM SUBMITTING THE FOLLOWING ADDITIONAL INFORMATION (If "NONE" write "NONE") (Attach additional page if needed):

CHECK BLOCK 1 AND THE STATEMENTS THAT APPLY OR CHECK BLOCK 2.
1. I (and/or my representative) wish to appear at a face-to-face disability hearing. The disability hearing will be with a person called a
disability hearing officer and it will let me explain why I do not agree with the decision to stop benefits.
I need an interpreter at the disability hearing - Language
(If you need an interpreter, SSA will provide one at no cost to you.)
OR
2. I do not wish to appear nor do I wish a representative to appear for me at the disability hearing. I have been advised of my right to have a
disability hearing. I understand that a disability hearing will give me a chance to present witnesses. It will also let me explain to the
disability hearing officer why my disability benefits should not end. I understand that this chance to be seen and heard could help the
disability hearing officer learn about the facts in my case. The disability hearing officer would give me a chance to have people who know
about my condition give information and explain how my condition keeps me from working and restricts my activities. I have been told
about my right to representation at the disability hearing, including representation by an attorney or other person of my choice. Although
the above has been explained to me, I do not want to appear at a disability hearing, or have someone represent me at a disability hearing. I
prefer to have the disability hearing officer decide my case on the evidence in my file, plus any evidence that I submit or that may be
obtained by the Social Security Administration. I have been advised that if I change my mind, I can request a disability hearing prior to the
writing of a decision in my case. In this case, I can make the request with any Social Security office.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is
true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact
in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
CLAIMANT SIGNATURE

EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH
SIGNATURE OR NAME OF CLAIMANT'S REPRESENTATIVE

STREET ADDRESS.
CITY

REPRESENTATIVE'S ADDRESS
STATE

TELEPHONE NUMBER

ZIP CODE

DATE

CITY
TELEPHONE NUMBER

STATE

ZIP CODE

DATE

Witnesses are required ONLY if this form has been signed by mark (X). If signed by mark (X), two witnesses to the signing who know the person
requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
Form

SSA-789-U4 (12-2009)

ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)

EF (12-2009) Use edition (3-2003) EF (07-2008) until supply is exhausted

CLAIMS FILE

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

See Revised Privacy Act

Sections 205(a), 1631(c)(1)(A) and (B), of the Social Security
Act, as amended, authorizes the collection of information on this
Statement
form. The information you provide will help us to determine your potential eligibility for benefit payments and to help us to decide
if additional information is needed. Your response is voluntary. However, failure to provide the requested information may
prevent an accurate and timely decision on any claim filed, or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for determining entitlement to benefit payments. In
accordance with 5 U.S.C. § 552a(b) of the Privacy Act, however, we may disclose the information provided on this form 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 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 determination for eligibility in similar health and income maintenance programs at the Federal, State, and local level;
and,
4) To facilitate statistical research, audit or investigate activities necessary to ensure 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 and for repayment of payment's or
delinquent debts under these programs.
A complete list of routine uses for this information is available in System of Records Notice 60-0089. The notice, additional
information regarding this form, and information regarding our programs and systems are available on-line at
www.socialsecurity.gov or at your local Social Security office.

See Revised PRA

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 15 minutes to read the instructions, gather the facts,
and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
To find the nearest office, call 1-800-772-1213 (TTY 1-800-325-0778). Send only comments on our time estimate above to:
SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.

Form

SSA-789-U4 (12-2009)

EF (12-2009)

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
PRIVACY ACT STATEMENT
Sections 205(a), 1631(c)(1)(A) and (B), of the Social Security Act, as amended, authorize us to collect the
information on this form. We will use this information to determine your potential eligibility for benefit
payments and to help us decide if we need additional information.
Furnishing us this information is voluntary. However, failure 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 provide for any purpose other than for determining entitlement to
benefit payments. However, we may use the information you give us for the administration and
integrity of our 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 us in establishing rights to Social Security
benefits and/or coverage;
2. To comply with federal laws requiring the release of information from our 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
at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement 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. We use
the information from these programs to establish or verify a person’s eligibility for federally-funded or
administered benefit programs and for repayment or incorrect payments or delinquent debts under
these programs.
A complete use of routine uses for this information is available in our Privacy Act Systems of Records
Notices, 60-0009, Hearings and Appeals Case Control System, 60-0010, Hearing Office Tracking System
of Claimant Cases, and 60-0089, Claims Folders Systems. These notices, additional information
regarding our programs and systems, are available online at www.socialsecurity.gov or at any local
Social Security office.

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. The OMB control number for this
collection is 0960-0349. We estimate that it will take about 13 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.