Information Collection

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)

IC 206582 under ICR 202108-0960-005 · OMB 0960-0710.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0710 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-85 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)	Form
HA-85 Request to Withdraw a Hearing Request HA-85 - Current Version.pdf	Form
HA-85 Request to Withdraw a Hearing Request HA-85 - Current Version.pdf	Form
HA-86 Request to Withdraw an Appeals Council Request for Revie HA-86 -Current Version.pdf	Form
HA-86 Request to Withdraw an Appeals Council Request for Revie HA-86 -Current Version.pdf	Form
e85 (submittable P Request to Withdraw a Hearing Request e85 Screen Package - Revised Version.pdf www.ssa.gov	Form and Instruction
e85 (submittable P Request to Withdraw a Hearing Request e85 Screen Package - Revised Version.pdf www.ssa.gov	Form and Instruction
e85 Screen Package - Current Version.pdf Current Version of the e85 (submittable PDF)	IC Document
e85 Screen Package - Current Version.pdf Current Version of the e85 (submittable PDF)	IC Document

IC Title:

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)

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 404.971 and 416.1471

Information Collection Instruments:

table that charts list of instruments
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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,606

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,606	1,606
Annual IC Time Burden (Hours)	268	268
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.