Form HA-504 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: [Claimant Name]

Social Security Number: [Claimant SSN]

Wage Earner:

Administrative Law Judge:

[Wage Earner]

Hearing Scheduled: [Hearing Date and Time]

Hearing Office: [Hearing Office]

Location of Hearing: [Room]
[Address]

(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 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.

See
Revised
Privacy
Act
Attached
We rarely use the information
you supply
us for any
purpose other
thanStatement
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 minute 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 (xx-2014)

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b)(1), 205(d) and 1631(c) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to acknowledge you will
appear at your hearing with an Administrative Law Judge.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. However, we may use the information for the administration of
our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0089, entitled Claims Folder System.
Additional information about this and other system of records notices and our programs are
available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through 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 of
incorrect payments or delinquent debts under these programs.