Request for Review of Hearing Decision/Order - Paper Version

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), 702, 1631(e), and 1869(b) and (c) 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 impact your request for an Appeals Council review of
an Administrative Law Judge’s decision on your claim.
We will use the information to support your request for a review of the decision or dismissal of
your claim. We may also share your information for the following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, for the purpose of assisting
SSA in the efficient administration of its programs. We contemplate disclosing
information under this routine use only in situations in which SSA may enter into a
contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records; and
2. 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; and 600089, entitled Claims Folders System. Additional information and a full listing of all our
SORNs are available on our website at https://www.ssa.gov/privacy/sorn.html.