Form HA-L90-OP1 Request to Show Cause for Failure to Appear

Form Approved

Social Security Administration

OMB No. 0960-0794

Office of Disability Adjudication and Review

Date:

REQUEST TO SHOW CAUSE FOR FAILURE TO APPEAR
Claimant:

Wage Earner:

Social Security Claim Number:

NOTE: Please read the PRIVACY ACT statement on the reverse page and the statements below.
You requested a hearing with an administrative law judge (ALJ). We scheduled a hearing for you
for
at .
You did not come to your hearing or contact us to explain why you could not attend.
If you still want an ALJ to hold a hearing on your claim, you may explain in writing why you did not come
to your hearing. You may print, write, or type your explanation in the space provided. You may include
another page if you need more space. Attach all supporting documentation. You must send your
explanation to us within 10 days from the date of this notice.
An ALJ will review your explanation. The ALJ will use rules in the Code of Federal Regulations to decide
if your explanation shows that you had a good reason for missing your hearing.
• If the ALJ decides that you had a good reason for missing your hearing, we will
schedule another hearing for you.
• If the ALJ decides that you did not have a good reason for missing your hearing, and
your representative also did not come to your hearing, the ALJ will decide your claim
based on the evidence in your file.
• If the ALJ decides that you did not have a good reason for missing your hearing, but
your representative came to your hearing, the ALJ will decide your claim based on the
evidence in your file.
If you do not return this form, or the ALJ decides that you did not have a good reason for missing
your hearing, the ALJ will decide your claim based on the evidence in your file.
I did not come to the hearing because:

Mail your explanation to: Office of Disability Adjudication and Review,
If you have any questions, you may call

SIGNATURE OF CLAIMANT (OR AUTHORIZED REPRESENTATIVE) DATE

Form HA-L90-OP1 (11-2015)

Privacy Act Statement
Collection of Personal Information
Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended authorize us to collect
this information. We will use this information to evaluate your reason for failing to appear at your
scheduled hearing.
Please See Revised Privacy Act Statement Attached
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
requested information may affect our ability to re-evaluate the decision on your claim.
We rarely use the information you supply for any purpose other than for determining problems in
Social Security programs. However, we may use it for the administration and integrity of Social
Security programs. 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 the Department of Veterans'
Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs
as at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity of Social Security programs.
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 use of routine uses for this information is available in our Systems of Records Notices,
60-0009, Hearings and Appeals Case Control System, and 60-0010, Hearing Office Tracking System
of Claimant Cases. These notices, additional information regarding our programs and systems, are
available on-line at www.socialsecurity.gov or at any 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 10 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 HA-L90-OP1 (11-2015)

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, 1631(d)(1), and 1872 of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or
part of the information may affect our ability to reevaluate the decision on the benefit eligibility
of the named claimant.
We will use the information to evaluate the reason for failing to appear at the scheduled hearing.
We may also share your information for the following purposes, called routine uses:
1. To a congressional office in response to an inquiry from that office made at the request of
the subject of a record; and
2. To third party contacts in situations where the party to be contacted has, or is expected to
have, information relating to the individual’s capability to manage his/her affairs or
his/her eligibility for or entitlement to benefits under the Social Security program when
the individual is unable to provide information being sought. An individual is considered
to be unable to provide certain types of information when he/she is incapable of or
questionable mental capability; he/she cannot read or write; a language barrier exists; or
the data are needed to establish the validity of evidence to verify the accuracy of
information presented by the individual, and it concerns his/her eligibility for benefits
under the Social Security program.
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) 60-0320, entitled Electronic Disability (eDIB) Claim File. Additional information and a
full listing of all our SORNs are available on our website at www.ssa.gov/privacy/sorn.html.