Form HA-L90-OP1 Request to Show Cause for Failure to Appear

Form Approved

Social Security Administration

OMB No. 0960-0794

Date:

REQUEST TO SHOW CAUSE FOR FAILURE TO APPEAR
Claimant:

Wage Earner:

Social Security Claim Number:

NOTE: Please read the PRIVACY ACT statement on the reverse page and the statements
below. You requested a hearing with a judge. We scheduled a hearing for you
for
at .
You did not come to your hearing or contact us to explain why you could not attend.
If you still want a judge to hold a hearing on your claim, you may explain in writing why you did not
come to your hearing. You may print, write, or type your explanation in the space provided. You may
include another page if you need more space. Attach all supporting documentation. You must send your
explanation to us within 10 days from the date of this notice.
A judge will review your explanation. The judge will use rules in the Code of Federal Regulations to
decide if your explanation shows that you had a good reason for missing your hearing.
• If the judge decides that you had a good reason for missing your hearing, we will
schedule another hearing for you.
• If the judge decides that you did not have a good reason for missing your hearing,
and your representative also did not come to your hearing, the judge will decide your
claim based on the evidence in your file.
• If the judge decides that you did not have a good reason for missing your hearing, but
your representative came to your hearing, the judge will decide your claim based on the
evidence in your file.
If you do not return this form, or the judge decides that you did not have a good reason for
missing your hearing, the judge will decide your claim based on the evidence in your file.
I did not come to the hearing because:

Mail your explanation to:
If you have any questions, you may call

SIGNATURE OF CLAIMANT (OR AUTHORIZED REPRESENTATIVE) DATE

Form HA-L90-OP1 (11-2015)

Privacy Act Statement
Collection of Personal Information
Sections 205, 1631(d)(1), and 1872 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 affect
our ability to reevaluate the decision on the benefit eligibility of the named claimant.
We will use the information to evaluate the reason for failing to appear at the scheduled hearing. We may also
share your information for the following purposes, called routine uses:

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

2. To third party contacts in situations where the party to be contacted has, or is expected to have,

information relating to the individual’s capability to manage his/her affairs or his/her eligibility for or
entitlement to benefits under the Social Security program when the individual is unable to provide
information being sought. An individual is considered to be unable to provide certain types of
information when he/she is incapable of or questionable mental capability; he/she cannot read or write;
a language barrier exists; or the data are needed to establish the validity of evidence to verify the
accuracy of information presented by the individual, and it concerns his/her eligibility for benefits under
the Social Security program.

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 Notice (SORN) 60-0320,
entitled Electronic Disability (eDIB) Claim File. Additional information and a full listing of all our SORNs are
available on our website at www.ssa.gov/privacy/sorn.html.
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 10 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.

Form HA-L90-OP1 (11-2015)