20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)

Request to Withdraw a Hearing Request; Request to Withdraw an Appeals Council Request for Review; and Administrative Review Process for Adjudicating Initial Disability Claims

OMB: 0960-0710

IC ID: 206582

Information Collection (IC) Details

View Information Collection (IC)

20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.971 and 416.1471

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HA-85 Request to Withdraw a Hearing Request HA-85 - Current Version.pdf No   Paper Only
Form HA-86 Request to Withdraw an Appeals Council Request for Review HA-86 -Current Version.pdf No   Paper Only
Form and Instruction e85 (submittable PDF) Request to Withdraw a Hearing Request e85 Screen Package - Revised Version.pdf www.ssa.gov Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

 

1,606 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,606 0 0 0 0 1,606
Annual IC Time Burden (Hours) 268 0 0 0 0 268
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Current Version of the e85 (submittable PDF) e85 Screen Package - Current Version.pdf 08/10/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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