Form SSA-769-U4 Request for Change in Time/Place of Disability Hearing

Form SSA-769 (09-2017) UF

Page 2 of 2

Privacy Act Statement
See Revised Privacy Act and
Collection and Use of Personal Information PRA Statements Attached

Section 205(b) of the Social Security Act, as amended, allows us to collect this information. We will use the
information you provide to attempt to reschedule a disability hearing based on good cause, eligibility, and
availability.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent you from receiving a new time or place of the hearing.
We rarely use the information you supply for any purpose other than what we state above, 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 list of when we may share your information with others, called routine uses, is available in our Privacy Act
System of Records Notices, 60.-0009, entitled Hearings and App�als C�se .Control System, and 60-0010,
entitled Hearing Office Tracking System of Claimant Cases. Additional information about these and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.
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 incorrect payments or delinquent debts under these
programs.

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 (0MB) control number.
We estimate that it will take about 20 minutes to read the in,structions, gat�er_ th� �acts, and answer the
questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.

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
Section 205(b) of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent you from receiving a new time and location for your disability hearing.
We will use the information you provide to determine whether to reschedule a disability hearing
based on good cause, eligibility, and availability. We may also share your information for the
following purposes, called routine uses:
 To a congressional office in response to an inquiry from that office made at the
request of the subject of a record; and
 To student volunteers, individuals working under a personal services contract, and
other workers who technically do not have the status of Federal employees, when
they are performing work for the Social Security Administration (SSA), as
authorized by.
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) 60-0009, Entitled Hearing and Appeals Case Control System, as published in the
Federal Register (FR) on October 13, 1983, at 47 FR 45589 and 60-0010, entitled Hearing Office
Tracking System of Claimant Cases, as published in the FR on January 11, 2006, at 71 FR
1806. Additional information, and a full listing of all our SORNs, is available on our website at
https://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
(OMB) control number. We estimate that it will take about 8 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.