Current SSA-769-U4

SSA-769 - Current Version.pdf

Request for Change in Time/Place of Disability Hearing

Current SSA-769-U4

OMB: 0960-0348

Document [pdf]
Download: pdf | pdf
Social Security Administration

Form Approved
OMB No. 0960-0348

TOE 710

REQUEST FOR CHANGE IN TIME/PLACE OF DISABILITY HEARING
(DO NOT WRITE IN THIS SPACE)

NAME OF CLAIMANT

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

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

TYPE OF
BENEFIT:

DISABILITY
WIDOW/
WIDOWER

WORKER

SSI
CHILD

DISABILITY

BLIND

CHILD

NAME OF REPRESENTATIVE, IF ANY
REPRESENTATIVE'S ADDRESS

HEARING CURRENTLY SCHEDULED
DATE
TIME

REQUEST

TELEPHONE NUMBER (INCLUDE
AREA CODE)

PLACE

A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE

A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)

THE REASON FOR MY REQUEST IS:

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

SIGN
HERE

u

DATE (MONTH, DAY, YEAR)
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)

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

Form SSA-769-U4 (07-2010) EF (07-2010)
Use old stock

Claims File

Privacy Act Notice
Collection and Use of Personal Information
Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended, and 20 C.F.R Parts
404.907-404.921, and 416.1407-416.1421, authorize us to collect this information. The purpose
of collecting this information is to track hearing office workload from the receipt of a request for a
hearing until the final hearing level disposition. Your response is voluntary. However, failure to
provide the requested information may prevent you from receiving a new time or place of the
hearing.
We rarely use the information provided on this form for any purpose other than for changing the
time/place of disability hearing. 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
Medicare benefits 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 of Medicare programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our 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 benefits programs and for repayment of payments or delinquent debts under these
programs.
Explanations about these and other reasons why information you provide us may be used are
available in Systems of Record Notice (SORN) 60-0009 (Hearings and Appeals Case Control System,
SSA, Office of Disability Adjudication and Review) and SORN 60-0010 (Hearing Office Tracking
System of Claimant Cases, SSA, Office of Disability Adjudication and Review). The notices,
additional information about this form, and any other information regarding our systems and
programs are available on-line at www.socialsecurity.gov or at your local Social Security office.
COMPUTER MATCHING SYSTEM: 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.
Explanations about these and other reasons why information about you may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
office.
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44
U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take you about 8 minutes to read the instructions, gather
the necessary facts, and answer the questions.

Social Security Administration

Form Approved
OMB No. 0960-0348

TOE 710

REQUEST FOR CHANGE IN TIME/PLACE OF DISABILITY HEARING
NAME OF CLAIMANT

(DO NOT WRITE IN THIS SPACE)

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

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

TYPE OF
BENEFIT:

SSI

DISABILITY
WIDOW/
WIDOWER

WORKER

CHILD

DISABILITY

BLIND

CHILD

NAME OF REPRESENTATIVE, IF ANY
TELEPHONE NUMBER (INCLUDE
AREA CODE)

REPRESENTATIVE'S ADDRESS

HEARING CURRENTLY SCHEDULED
DATE
TIME

REQUEST

PLACE

A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)

A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE

THE REASON FOR MY REQUEST IS:

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

SIGN
HERE

u

DATE (MONTH, DAY, YEAR)
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)

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

Form SSA-769-U4 (07-2010) EF (07-2010)
Use old stock

DHU Copy

Privacy Act Notice
Collection and Use of Personal Information
Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended, and 20 C.F.R Parts
404.907-404.921, and 416.1407-416.1421, authorize us to collect this information. The purpose
of collecting this information is to track hearing office workload from the receipt of a request for a
hearing until the final hearing level disposition. Your response is voluntary. However, failure to
provide the requested information may prevent you from receiving a new time or place of the
hearing.
We rarely use the information provided on this form for any purpose other than for changing the
time/place of disability hearing. 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
Medicare benefits 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 of Medicare programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our 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 benefits programs and for repayment of payments or delinquent debts under these
programs.
Explanations about these and other reasons why information you provide us may be used are
available in Systems of Record Notice (SORN) 60-0009 (Hearings and Appeals Case Control System,
SSA, Office of Disability Adjudication and Review) and SORN 60-0010 (Hearing Office Tracking
System of Claimant Cases, SSA, Office of Disability Adjudication and Review). The notices,
additional information about this form, and any other information regarding our systems and
programs are available on-line at www.socialsecurity.gov or at your local Social Security office.
COMPUTER MATCHING SYSTEM: 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.
Explanations about these and other reasons why information about you may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
office.
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44
U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take you about 8 minutes to read the instructions, gather
the necessary facts, and answer the questions.

Social Security Administration

Form Approved
OMB No. 0960-0348

TOE 710

REQUEST FOR CHANGE IN TIME/PLACE OF DISABILITY HEARING
NAME OF CLAIMANT

(DO NOT WRITE IN THIS SPACE)

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

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

TYPE OF
BENEFIT:

DISABILITY

SSI

WIDOW/
WIDOWER

WORKER

CHILD

DISABILITY

BLIND

CHILD

NAME OF REPRESENTATIVE, IF ANY
TELEPHONE NUMBER (INCLUDE
AREA CODE)

REPRESENTATIVE'S ADDRESS

HEARING CURRENTLY SCHEDULED
DATE
TIME

PLACE

A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)

A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE

REQUEST

THE REASON FOR MY REQUEST IS:

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

SIGN
HERE

u

DATE (MONTH, DAY, YEAR)
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)

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

Form SSA-769-U4 (07-2010) EF (07-2010)
Use old stock

Claimant Copy

Privacy Act Notice
Collection and Use of Personal Information
Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended, and 20 C.F.R Parts
404.907-404.921, and 416.1407-416.1421, authorize us to collect this information. The purpose
of collecting this information is to track hearing office workload from the receipt of a request for a
hearing until the final hearing level disposition. Your response is voluntary. However, failure to
provide the requested information may prevent you from receiving a new time or place of the
hearing.
We rarely use the information provided on this form for any purpose other than for changing the
time/place of disability hearing. 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
Medicare benefits 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 of Medicare programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our 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 benefits programs and for repayment of payments or delinquent debts under these
programs.
Explanations about these and other reasons why information you provide us may be used are
available in Systems of Record Notice (SORN) 60-0009 (Hearings and Appeals Case Control System,
SSA, Office of Disability Adjudication and Review) and SORN 60-0010 (Hearing Office Tracking
System of Claimant Cases, SSA, Office of Disability Adjudication and Review). The notices,
additional information about this form, and any other information regarding our systems and
programs are available on-line at www.socialsecurity.gov or at your local Social Security office.
COMPUTER MATCHING SYSTEM: 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.
Explanations about these and other reasons why information about you may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
office.
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44
U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take you about 8 minutes to read the instructions, gather
the necessary facts, and answer the questions.

Social Security Administration

Form Approved
OMB No. 0960-0348

TOE 710

REQUEST FOR CHANGE IN TIME/PLACE OF DISABILITY HEARING
NAME OF CLAIMANT

(DO NOT WRITE IN THIS SPACE)

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

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

TYPE OF
BENEFIT:

DISABILITY
WIDOW/
WIDOWER

WORKER

SSI
CHILD

DISABILITY

BLIND

CHILD

NAME OF REPRESENTATIVE, IF ANY
TELEPHONE NUMBER (INCLUDE
AREA CODE)

REPRESENTATIVE'S ADDRESS

HEARING CURRENTLY SCHEDULED
DATE
TIME

REQUEST

PLACE

A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)

A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE

THE REASON FOR MY REQUEST IS:

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

SIGN
HERE

u

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

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

CITY AND STATE

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-769-U4 (07-2010) EF (07-2010)
Use old stock

Other

Privacy Act Notice
Collection and Use of Personal Information
Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended, and 20 C.F.R Parts
404.907-404.921, and 416.1407-416.1421, authorize us to collect this information. The purpose
of collecting this information is to track hearing office workload from the receipt of a request for a
hearing until the final hearing level disposition. Your response is voluntary. However, failure to
provide the requested information may prevent you from receiving a new time or place of the
hearing.
We rarely use the information provided on this form for any purpose other than for changing the
time/place of disability hearing. 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
Medicare benefits 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 of Medicare programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our 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 benefits programs and for repayment of payments or delinquent debts under these
programs.
Explanations about these and other reasons why information you provide us may be used are
available in Systems of Record Notice (SORN) 60-0009 (Hearings and Appeals Case Control System,
SSA, Office of Disability Adjudication and Review) and SORN 60-0010 (Hearing Office Tracking
System of Claimant Cases, SSA, Office of Disability Adjudication and Review). The notices,
additional information about this form, and any other information regarding our systems and
programs are available on-line at www.socialsecurity.gov or at your local Social Security office.
COMPUTER MATCHING SYSTEM: 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.
Explanations about these and other reasons why information about you may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
office.
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44
U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take you about 8 minutes to read the instructions, gather
the necessary facts, and answer the questions.


File Typeapplication/pdf
File TitleRequest for Change in Time/Place of Disability Hearing
SubjectRequest for Change in Time/Place of Disability Hearing
AuthorSSA
File Modified2015-11-18
File Created2014-02-06

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