Waiver of Right to Appear--Disability Hearing

SSA will insert the following revised Privacy Act and PRA Statements into the form as soon as
possible:
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, allow
us to collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent an accurate and timely decision on your
waiver request.
We will use the information to acknowledge your decision to waive the right to a disability
hearing and to determine your waiver eligibility. We may also share your information for the
following purposes, called routine uses:


To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs; and



To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for SSA as authorized by law, and
they need access to personally identifiable information in SSA records in order to
perform their assigned Agency functions.

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 Notices
(SORN) 60-0005, entitled Administrative Law Judge Working File on Claimant Cases, as
published in the Federal Register (FR) on April 29, 2009, at 74 FR 19617, and 60-0089, entitled
Claims Folders Systems, as published in the FR on April 1, 2003, at 68 FR 15784. Additional
information and a full listing of all our SORNs are available on our website at
www.ssa.gov/privacy.
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 3 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 1-800772-1213 (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.