Form SSA-765 Response to Notice of Revised Determination

SOCIAL SECURITY ADMINISTRATION

TOE 710

RESPONSE TO NOTICE OF REVISED DETERMINATION
NAME OF CLAIMANT

SOCIAL SECURITY NUMBER

NAME OF WAGE EARNER OR SELF EMPLOYED PERSON
(IF DIFFERENT FROM CLAIMANT)

SOCIAL SECURITY NUMBER

Form Approved
OMB No. 0960-0347
DO NOT WRITE IN THIS
SPACE

SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPLETE ONLY IN
SUPPLEMENTAL SECURITY INCOME CASE)

DISABILITY

SSI

TYPE OF BENEFIT:
WORK

BLIND

CHILD

I wish to appear at a Disability Hearing (includes representative appearing)

YES

NO

I have additional evidence or information to submit

YES

NO

If "Yes," check as many as appropriate:
EVIDENCE

WIDOW

CHILD

DISABILITY

I WILL FURNISH THE FOLLOWING EVIDENCE:

I cannot furnish any or all additional evidence. I have the following information or sources of evidence to provide:

I NEED AN INTERPRETER

YES

CHECK
If "Yes," complete
LANGUAGE
ONE
this line
NAME OF REPRESENTATIVE (IF ANY)
REPRESENTATIVE'S ADDRESS

NO

SSA NEEDS TO
I WILL
PROVIDE
PROVIDE
TELEPHONE NUMBER
(INCLUDE AREA CODE)

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

DATE (MONTH, DAY, YEAR)

SIGN
HERE

TELEPHONE NUMBER
(INCLUDE AREA CODE)

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)

Form SSA-765 (03-2013) Use Prior Editions EF (03-2013)

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

(See information on reverse)

Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) and 1631(e)(1)(A) of the Social Security Act, as amended, authorize us to collect this information. We will
use the information you provide to fully evaluate your claim for disability benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information will result in us
making a decision based on evidence in your file.
We rarely use the information you supply for any purpose other than to evaluate your claim for disability benefits. 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 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 (e.g., to the Bureau of the Census).
We may also use the information you provide 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 for this information is available in our System of Records Notice entitled, Claims Folders
Systems, 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.

Form SSA-765 (03-2013) (Back) EF (03-2013)