Form HA-4608 Waiver of Right to Personal Appearance Before an Adminis

Form Approved
OMB No. 0960-0284

Social Security Administration/Office of Disability Adjudication and Review

WAIVER OF YOUR RIGHT TO PERSONAL APPEARANCE BEFORE A JUDGE
Claimant

Wage Earner (Leave blank if same as claimant)

Social Security Claim Number

-

-

NOTE: Please read the PRIVACY ACT statement on reverse and the statements below. Then, print, write,
or type your response to the statements in the space provided below. If you need more space,
attach a separate page to this form.
I have been advised of my right to appear in person before a judge. I understand that my personal appearance
before a judge would provide me with the opportunity to present written evidence, my testimony, and the
testimony of other witnesses. I understand that this opportunity to be seen and heard could be helpful to the
judge in making a decision.
Although my right to a personal appearance before a judge has been explained to me, I do not want to appear in
person. I want to have my case decided on the written evidence. The reason I do not want to appear in person
at a hearing is:

I understand that if I do not appear before a judge, I still have the right to present a written summary of my case,
or to enter written statements about the facts and law material to my case in the record.
If I change my mind and decide to request a personal appearance before the judge, I understand that I should
make this request to the office conducting the hearing before the judge’s decision is mailed to me.
I understand that I have a right to be represented and that if I need representation, the Social Security office or
office conducting the hearing can give me a list of legal referral and service organizations to assist me in locating
a representative.
SIGNATURE OF CLAIMANT (OR AUTHORIZED REPRESENTATIVE)

Form HA-4608 (3-2016)
Prior editions may be used

DATE

PRIVACY ACT NOTICE
Sections 205(a), 1631(d)(i), 1631(e)(i)(ii), and 1869(b), of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to make a determination on your claim without
an oral hearing.
See Revised Privacy Act Statement Attached
Furnishing us the information is voluntary. However, failing to provide us with all or part of the requested
information may affect the decision on your claim.
We rarely use the information for any purpose other than for making a decision regarding continuing entitlement
to benefits. However, we may use it for the administration and integrity of our programs. We may also disclose
the information to another person or to another agency in accordance with approved routine uses, including, but
not limited to the following:
1.

To enable a third party or an agency to assist us in establishing rights to our benefits and coverage;

2.

To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs);

3.

To make determinations for eligibility in similar heath and income maintenance programs at the
Federal, State, and local level; and,

4.

To facilitate statistical research, audit, and investigatory activities necessary to assure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract
with us).

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. We use the information from
these programs to establish or verify a person’s eligibility for federally funded and administered benefit programs
and for repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act Systems of Records Notices
entitled, Hearing and Appeals Case Control System, 60-009 and Claims Folders Systems, 60-0089. These notices,
additional information regarding our programs and systems are available on-line at www.socialsecurity.gov or at
your 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 2 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You
can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices
are also 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 HA-4608 (3-2016)

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(e), and 1869(b) of the Social Security Act, as amended, and 20 CFR
404.948(b)(1)(I), 404.956, 416.1448(b)(1)(i), and 416.1456 allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may affect the decision on your claim.
We will use the information to make a decision regarding continuing entitlement to benefits. We
may also share your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies that conduct business with the Social Security
Administration (SSA) and the release of records is determined to be relevant and
necessary to the litigation; and disclosure is compatible to the reason why the records
were collected;
2. To third party contacts when additional information about the party filing the waiver is
needed or verification of eligibility for benefits; and
3. To workers who are performing work for SSA as authorized by law and who technically
do not have the status of Federal employees; and other Federal agencies for assisting SSA
in the efficient administration of its programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-009, entitled Hearing and Appeals Case Control System; and 60-0089, entitled
Claims Folders Systems. Additional information and a full listing of all our SORNs are available
on our website at www.socialsecurity.gov/foia/bluebook.