Request for Hearing By Administrative Law Judge--Paper/MCS/MSSICS Versions

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, 1155, 1631(c), and 1869(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 us from making an accurate and timely
decision on your claim.
We will use the information you provide to continue processing your claim. 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
Social Security Administration (SSA) in the efficient administration of its programs. We
contemplate disclosing information under this routine use only in situations in which SSA
may enter a contractual or similar agreement with a third party to assist in accomplishing
an agency function relating to this system of records; and

•

To a congressional office in response to an inquiry from that office made at the request of
the subject of a record.

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 Hearings and Appeals Case Control System, as published in the
Federal Register (FR) on October 13, 1982, at 47 FR 45589 and 60-0089, entitled Claims Folder
System, as published in the FR on April 1, 2003, at 68 FR 15784. Additional information, and a
full listing of all of our SORNs, is 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 10 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.