Information Collection

20 CFR 404.971 and 416.1471 (Request to Withdraw a Hearing Request; Request to Withdraw an Appeals Council Request for Review)

IC 206582 under ICR 201606-0960-005 · OMB 0960-0710.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0710 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-85 20 CFR 404.971 and 416.1471 (Request to Withdraw a Hearing Request; Request to Withdraw an Appeals Council Request for Review)	Form
HA-85 - Revised PA Statement.pdf	Other-Revised PA Statement
HA-86 - Revised PA Statement.pdf	Other-Revised PA Statement
HA-85 Request to Withdraw a Hearing Request HA-85 - Revised.pdf	Form
HA-86 Request to Withdraw an Appeals Council Request for Revie HA-86 - Revised.pdf	Form
HA-85 - Current.pdf HA-85 - Current	IC Document
HA-86 - Current.pdf HA-86 - Current	IC Document

IC Title:

20 CFR 404.971 and 416.1471 (Request to Withdraw a Hearing Request; Request to Withdraw an Appeals Council Request for Review)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.971 and 416.1471

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	HA-85	Request to Withdraw a Hearing Request	HA-85 - Revised.pdf	No	Paper Only
Form	HA-86	Request to Withdraw an Appeals Council Request for Review	HA-86 - Revised.pdf	No	Paper Only
Other-Revised PA Statement			HA-85 - Revised PA Statement.pdf	No	Paper Only
Other-Revised PA Statement			HA-86 - Revised PA Statement.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: 1,606

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	1,606	1,606
Annual IC Time Burden (Hours)	268	268
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HA-85 - Current	HA-85 - Current.pdf	07/19/2016
HA-86 - Current	HA-86 - Current.pdf	07/19/2016

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