Information Collection

Request for Change in Time/Place of Disability Hearing

IC 9228 under ICR 201511-0960-002 · OMB 0960-0348.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0348 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-769-U4 Request for Change in Time/Place of Disability Hearing	Form
SSA-769-U4 Request for Change in Time/Place of Disability Hearing SSA-769 - Revised Version.pdf	Form
SSA-769 - Current Version.pdf Current SSA-769-U4	IC Document

IC Title:

Request for Change in Time/Place of Disability Hearing

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.914(c)(2) 20 CFR 416.1414(c)(2)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-769-U4	Request for Change in Time/Place of Disability Hearing	SSA-769 - Revised Version.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,483

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	7,483	7,483
Annual IC Time Burden (Hours)	998	998
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-769-U4	SSA-769 - Current Version.pdf	11/18/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.