Request for Review of Hearing Decision/Order - Paper Version

Request for Review of Hearing Decision/Order

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0277 can be found here:

Documents and Forms

Document Name Document Type
Form HA-520 Request for Review of Hearing Decision/Order - Paper Version Form
HA-520 - Revised PA Statement.pdf www.ssa.gov Other-Revised Privacy Act Statement
HA-520 Request for Review of Hearing Decision/Order Revised_HA-520_Mockup (002).pdf www.ssa.gov Form
HA-520 - Current Version.pdf Current HA-520 IC Document

Information Collection (IC) Details

IC Title:	Request for Review of Hearing Decision/Order - Paper Version	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.967-404.981 20 CFR 416.1467-416.1481

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-520	Request for Review of Hearing Decision/Order	Revised_HA-520_Mockup (002).pdf	www.ssa.gov	Yes	No	Fillable Printable
Other-Revised Privacy Act Statement			HA-520 - Revised PA Statement.pdf	www.ssa.gov	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 105,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	105,000	105,000
Annual IC Time Burden (Hours)	17,500	17,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current HA-520	HA-520 - Current Version.pdf	03/23/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.