SSA-773 Current Version

Form Approved
OMB No. 0960-0534

TOE 710

SOCIAL SECURITY ADMINISTRATION

WAIVER OF RIGHT TO APPEAR - DISABILITY HEARING

(DO NOT WRITE IN THIS SPACE)

NAME OF CLAIMANT
NAME OF WAGE EARNER OR SELF-EMPLOYED

SOCIAL SECURITY NUMBER

(COMPLETE ONLY IN SUPPLEMENTAL SECURITY INCOME CASE)

NAME OF SPOUSE
TYPE
OF
BENEFIT

SOCIAL SECURITY NUMBER

DISABILITY

WORKER

SSI

WIDOW/
WIDOWER

CHILD

DISABILITY

BLIND

CHILD

NAME OF REPRESENTATIVE, IF ANY
REPRESENTATIVE'S ADDRESS

TELEPHONE NUMBER (INCLUDE
AREA CODE)

I have been advised of my right to have a disability hearing. I understand that a hearing will give me an
opportunity to present witnesses and explain in detail to the disability hearing officer, who will decide my case,
the reasons why my disability benefits should not end. I understand that this opportunity to be seen and heard
could be effective in explaining the facts in my case, since the disability hearing officer would give me an
opportunity to present and question witnesses and explain how my impairments prevent me from working and
restrict my activities. I have been given an explanation of my right to representation, including representation at a
hearing 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 of record plus any evidence which I may submit or which may be obtained by the Social Security
Administration. I have been advised that if I change my mind, I can request a hearing prior to the writing of a
decision in my case. In this event, I can make the request with any Social Security office.

SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)

SIGN
HERE

DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER (INCLUDE
AREA CODE)

u

MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
CITY AND STATE

ZIP CODE

Witnesses are required ONLY if this form has been signed by mark (X) above. 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)

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

Form SSA-773-U4 (08-2012) ef(08-2012)

4 copies: Claims File, DHU, Claimant, Other

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(e)(1)(A) and (B), and 1872 of the Social Security Act, as amended, authorize us to
collect the information on this form. We will use the information you provide to act on your request to waive
your right to appear at a disability hearing.
Your response is voluntary. However, failing to provide us with all or part of the information could result in
our inability to act on your waiver request.
We rarely use the information you provide for any purpose other than for determining waiver eligibility. 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 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.
We may also use the information you provide in computer matching programs. Computer matching
programs compare our records with those of other Federal, State, or local government agencies. We can
use information from these matching programs 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 for this information is available in our System of Records Notices entitled,
Claims Folders Systems (60-0089) and Administrative Law Judge Working File on Claimant Cases
(60-0005). These notices, additional information regarding this form, and information regarding our
programs and systems, are available on-line at http://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 control number. We
estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the
questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office
is listed under U.S. Government agencies in your telephone directory or you may call Social
Security at 1-800-772-1213 (TTY 1-800-325-0778). 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 SSA-773-U4 (08-2012) ef(08-2012)