Addendum to the Supporting Statement 0960-0671

Addendum to the Supporting Statement for

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

Form HA-L83, Acknowledgement of Receipt (Notice of Hearing) Cover Letter

Form HA-55, Objection to Appearing by Video Teleconferencing

Form HA-510, Waiver of Written Notice of Hearing

20 CFR 404.936, 404.938, 416.1436, 416.1438, 405.316

OMB No. 0960-0671

Minor Revisions to the Collection Instrument

SSA is making the following revisions to this collection:

• We are adding a new form, Form HA-55, to the information collection as a result of our new regulations. Form HA-55 will accommodate our new requirement allowing 30 days for the claimant to request an in-person hearing rather than a video teleconference hearing. The cover letter for the HA-55 will also explain SSA’s right to determine if the claimants will appear via video teleconferencing if they change their residences while the request for hearing is pending

• To accommodate our new requirement for claimants to inform us of their wish to object no later than five days prior to the hearing or 30 days after receiving the HA‑504, Notice of Hearing, we are modifying the language in our HA-504 cover letter, the HA-L83. The new cover letter language will explain the claimants’ right to object, and let them know how to notify SSA if they choose to do so.

• We are adding the HA-510 to this information collection, as we use it to allow claimants to inform SSA of their wish not to receive a Notice of Hearing. Prior to our revision to the regulations, we created and used this form and inadvertently did not obtain OMB approval for the usage. Since we estimate approximately 4,000 respondents use this form annually, we are bringing it into compliance with the Paperwork Reduction Act now. In addition, since we are revising our Regulations allowing claimants to notify SSA that they wish to waive their right to receive Notice of Hearing, we are adding the HA-510 to this collection as it pertains to the Notice of Hearing.

• Finally, in compliance with our new regulations, we are adjusting the language on the checkboxes of Form HA-504 to remove the option for a video teleconference hearing, as the respondents will already answer that question using Form HA-55. In addition, we are making small revisions as necessary to the HA-L83 cover letter to provide clarity to the claimant respondents of Form HA-504.

• To ensure respondents can comment on the new HA-55, as well as the revised HA‑L83 and HA‑504, we are submitting this information collection request to OMB simultaneously with the publication of the NPRM in the Federal Register on June 27, 2013 at 78 FR 38610.

• Since the revised version of Form HA-504 will mirror the current HA-504-OP1, we are replacing the HA-504-OP1 with the revised HA-504. We will discontinue use of the current HA-504-OP1, and will rename the HA-540-OP2 making it “HA-504-OP1” (see the last bullet below for more details).

• In addition, SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the HA-504.

• SSA is also updating the Paperwork Reduction Act Statement for the HA-504 to reflect our revised boilerplate language.  The current language, which dates back to the last reprint of the form, is now outdated.

• Upon OMB’s approval of this Information Collection Request, we will discontinue use of the current HA-504-OP1, and rename our current HA-504-OP2, calling it “HA-504-OP1.” The renamed HA-504-OP2 will continue to be our phone teleconference hearing form (however, we will call it “HA-504-OP1”). Since our internal Document Generation System (DGS) is the only way we generate and print the HA-504, HA-L83, and new HA-55, and we only generate and print these forms when sending a Notice of Hearing to the claimant, there is no old stock for us to destroy. We will simply remove the HA‑504‑OP1 from DGS; add the HA-55 to DGS, rename the HA-504-OP2; and replace the current versions of the HA-504 and HA-L83 with the revised versions.