SSA-773-U4 Waver of Right to Appear--Disability Hearing

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No 0960-0534

TOE 710

(DO NOT WRITE IN THIS SPACE)

WAIVER OF RIGHT TO APPEAR - DISABILITY HEARING

NAME OF CLAIMANT
NAME OF WAGE EARNER OR SELF-EMPLOYED

SOCIAL SECURITY NUMBER

(COMPLETE ONLY IN SUPPLEMENTAL SECURITY INCOME CASE)
NAME OF SPOUSE
SOCIAL SECURITY NUMBER

TYPE
OF
BENEFIT

DISABILITY

D

WORKER

D

WIDOW/
WIDOWER

SSI

D

CHILD

D

DISABILITY

D

BLIND

D

CHILD

NAME OF REPRESENTATIVE, IF ANY
REPRESENTATIVE'S ADDRESS

TELEPHONE NUMBER (INCLUDE
AREA CODE)

I have been advised of my right to have a disability hearing. I understand that a hearing will give me an
opportunity to present witnesses and explain in detail to the disability hearing officer, who will decide my case,
the reasons why my disability benefits should not end. I understand that this opportunity to be seen and heard
could be effective in explaining the facts in my case, since the disability hearing officer would give me an
opportunity to present and question witnesses and explain how my impairments prevent me from working and
restrict my activities. I have been given an explanation of my right to representation, including representation at a
hearing by an attorney or other person of my choice.
Although the above has been explained to me, I do not want to appear at a disability hearing, or have someone
represent me at a disability hearing. I prefer to have the disability hearing officer decide my case on the
evidence of record plus any evidence which I may submit or which may be obtained by the Social Security
Administration. I have been advised that if I change my mind, I can request a hearing prior to the writing of a
decision in my case. In this event, I can make the request with any Social Security office.

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

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

SIGN ......_
HERE Jlllllll"'"

MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
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-773-U4 (08-2012) ef(OB-2012)

4 copies: Claims File, DHU, Claimant, Other

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(e)(1)(A and (B), and 1872 of the SocialS urity Act, as amended, authorize I.JS to
collect the information on this orm. We will use the information y u provide to act on your request t1waive
your right to appear at a dis ility hearing.
Your response is volunta . However, failing to provide us wit all or part of the information could result in
our inability to act on you waiver request.
/

el~·~ility.

We rarely use the infor ation you provide for any purpose ther than for determining waiver
In
accordance with 5 U.. C.§ 552a(b) of the Privacy Act, ho ever, we may disclose the informati n provided
on this form in accor ance with approved routine uses, w ich include but are not limited to the! ollowing:
j

1. To enable a t ird party or an agency to assist So al Security in establishing rights to s/cial
Security be fits and/or coverage;
I
I
f

2. To comply, with Federal laws requiring the rele se of information from Social Security/records (e.
g., to the overnment Accountability Office a Department of Veterans' Affairs); /
3. To rna determinations for eligibility in simi r health and income maintenance pro~ rams at the
/
Feder I, State, and local level; and,
4. To f cilitate statistical research, audit, or· vestigative activities necessary to assire the integrity
1
an improvement of Social Security pro ams.
We m also use the information you provid in computer matching programs. Com uter matching
progr ms compare our records with those other Federal, State, or local governm nt agencies. We can
use · formation from these matching progr; ms to establish or verify a person's elig bility for federally-funded
or ministered benefit programs and for epa S
. d
r delinquent de ts under
ee rev1se
th e programs.
Privacy Act
Statement below.
.
.
r System of Records Not ces ent1tled,
A complete list f routine uses for is informa
Claims Folder; Systems (60-00 ) and Administrative Law Judge Working File on Claim t Cases
(60-0005). T ese notices, ad tional information regarding this form, and information re arding our
programs nd systems, ar available on-line at http://www.socialsecurity.gov or at yo" r local Social
Security ffice.
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 15 minutes to read the instructions, gather the facts, and answer the
questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office
is 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 SSA-773-U4 (08-2012) ef(OB-2012)

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and (b) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you provide to
acknowledge your waiver of right to appear at a disability hearing.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on your waiver request.
We rarely use the information you supply us for any purpose other than to make a determination
regarding waiver eligibility. However, we may use the information for the administration of our
programs including sharing information:
1. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices 60-0089, entitled Claims Folders
Systems and 60-0005, entitled Administrative Law Judge Working File on Claimant Cases.
Additional information about these and other system of records notices and our programs are
available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through 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 or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.