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:

Administrative Law Judge:

Hearing Scheduled:

Hearing Office:

Location of Hearing:

(Check only one)
[ ] 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:

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:

Area Code and Telephone Number:

[ ] 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, we may provide information 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 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.

See Revised Privacy Act Statement Attached

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, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed
form.
Form HA 504 (09-2003) ef (10-2004)
Form HA 504-OP1 (09-2003) ef (10-2004)

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 702, 1631(e)(1)(A) and (B), and (1869)(b)(1) and (c) of the Social Security Act,
as amended, authorize us to collect this information. We will use the information you provide to
continue processing your claim.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making an accurate and timely decision on your claim and
may affect the receipt of benefits under the Social Security Act.
We rarely use the information you supply us for any purpose other than to process your claim.
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 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 and improvement of Social Security programs (e.g., to the Bureau of the
Census).
We may also use the information you give us 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 of the information you provided us 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 your local Social Security office.