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

Form Approved
OMB NO. 0960-0671

ACKNOWLEDGMENT 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 do not want to appear at my hearing by video teleconference. Please reschedule my hearing so that I may
appear before you in person. We are removing this option from the form per our new regulations which state the claimants will have to make their
VTC election earlier in the process using a different form.

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:

See Revised Privacy Act Statement Attached

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 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 to the Department of Justice to represent the Federal Government in a court suit related to a program administered by the Social
Security Administration.
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.
See Revised PRA Attached

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 1 minute 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 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.

Form HA-504 (09-2003) ef (10-2004)

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
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.
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 about 30 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.