Information Collection

Acknowledgement of Receipt (Notice of Hearing) - HA-504 (with teleconferencing)

IC 9725 under ICR 202101-0960-009 · OMB 0960-0671.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0671 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-504 Acknowledgement of Receipt (Notice of Hearing) - HA-504 (with teleconferencing)	Form
HA-L83 - Current Version (Non COVID-related).pdf	Other-Cover Letter and Instructions
HA-L83 - Current MS Teams Version.pdf	Other-Cover Letter and Instructions
HA-504 Acknowledgement of Receipt (Notice of Hearing) HA-504 - Revised Version.pdf	Form
HA-504-OP2 ACKNOWLEDGEMENT OF RECEIPT (NOTICE OF HEARING) HA-504-OP2 - Revised Version.pdf	Form
HA-504 - Current Version.pdf Current HA-504	IC Document
HA-504-OP2 - Current Version.pdf Current HA-504-OP2	IC Document

IC Title:

Acknowledgement of Receipt (Notice of Hearing) - HA-504 (with teleconferencing)

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 416.1438 20 CFR 404.938

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	HA-504	Acknowledgement of Receipt (Notice of Hearing)	HA-504 - Revised Version.pdf	No	Paper Only
Form	HA-504-OP2	ACKNOWLEDGEMENT OF RECEIPT (NOTICE OF HEARING)	HA-504-OP2 - Revised Version.pdf	No	Paper Only
Other-Cover Letter and Instructions			HA-L83 - Current Version (Non COVID-related).pdf	No	Paper Only
Other-Cover Letter and Instructions			HA-L83 - Current MS Teams Version.pdf	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 898,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	898,000	898,000
Annual IC Time Burden (Hours)	449,000	449,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-504	HA-504 - Current Version.pdf	01/29/2021
Current HA-504-OP2	HA-504-OP2 - Current Version.pdf	01/29/2021

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