Information Collection

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

IC 9174 under ICR 201910-0960-002 · OMB 0960-0269.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0269 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-501 Request for Hearing By Administrative Law Judge--Paper/MCS/MSSICS Versions	Form and Instruction
Form HA-501 Request for Hearing By Administrative Law Judge Request for Hearing By Administrative Law Judge--Paper/MCS/MSSICS Versions	Form and Instruction
SSI Claims System Appeals Screens in Path Order.pdf	Other-Internal SSI Claims System Scr
SSI Claims System Appeals Screens in Path Order.pdf	Other-Internal SSI Claims System Scr
MCS Appeals screens - HA-501.docx	Other-Internal MCS Screens
MCS Appeals screens - HA-501.docx	Other-Internal MCS Screens
HA-501 - Revised PA Statement.pdf	Other-Revised PA and PRA Statements
HA-501 - Revised PA Statement.pdf	Other-Revised PA and PRA Statements
HA-501 Request for Hearing By Administrative Law Judge HA-501 - Revised Version.pdf	Form and Instruction
HA-501 Request for Hearing By Administrative Law Judge HA-501 - Revised Version.pdf	Form and Instruction
HA-501 - Current Version.pdf Current HA-501	IC Document
HA-501 - Current Version.pdf Current HA-501	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.929 20 CFR 405.722 20 CFR 416.1429 20 CFR 404.1433 20 CFR 418.1350 20 CFR 404.933

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HA-501	No		Paper Only
Other-Internal SSI Claims System Screens		Yes	Yes	Fillable Fileable Signable
Other-Internal MCS Screens		Yes	Yes	Fillable Fileable Signable
Other-Revised PA and PRA Statements		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,325

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,325	-628	10,953
Annual IC Time Burden (Hours)	1,721	-105	1,826
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-501		10/11/2019

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

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