Justification for the Non-Substantive Changes for 0960-0710 (IT Mod Change Request)

Justification for Non-Substantive Changes to Form HA-86:

Request to Withdraw an Appeals Council Request for Review

20 CFR 404.971 and 416.972

OMB No. 0960-0710

Background

If a claimant wishes to withdraw a request for Appeals Council review before the Appeals Council grants or denies review, the Appeals Council may dismiss the request. The claimant can make the request to withdraw the Appeals Council request in writing. In addition, the agency created Form HA-86 for claimants and representatives to use as written notice of the withdrawal of a request for Appeals Council review. While use of Form HA-86 is voluntary (as the claimant or representative may request the withdrawal in writing separately from the use of the form), the form captures the key information required to process the request.

While we still accept, and will continue to accept, paper versions of the HA-86 and other written requests for withdrawal of a hearing request, we created an online fillable and submittable version of the HA-86, which utilizes Adobe Sign technology to accept and process an electronic signature (eSignature). The online version of the HA-86 mirrors the paper version and provides respondents with an online service option as an alternative to mailing or faxing the form (or their written request) to the servicing hearing office. Claimants and appointed representatives will be able to initiate the online version from our website and complete, electronically sign, and submit it online using the Adobe Sign web application. Use of the Adobe Sign web application does not present any added burden on respondents. Respondents will not be required to download and install the application locally on their device, nor will they have to pay any subscription or licensing fees.

With this new modality for submission, respondents will enter their responses into structured data fields on the online HA-86 screens within the Adobe platform by following a secure link that Adobe Sign sends to the email address the respondent (i.e., claimant or appointed representative) provides. The respondent receives an email from Adobe Sign with instructions for how to access, complete, electronically sign, and submit the form using this online service. Upon submission, the online HA-86 electronically transmits an image of the completed form to the Electronic Viewing System (eVIEW) for processing by the Appeals Council. Once received in eVIEW, the Appeals Council will process the request for withdrawal of an Appeals Council request for review using current business processes and policies. Finally, the respondent can download a copy immediately after signing, within the application, for their records.

The email link to the submittable HA-86 will be available to the respondent for five days, during which Adobe Sign will send daily email reminders to ensure timely submission and prevent unnecessary delays in processing the withdrawal request. After those five days, the link will expire, and the respondent will need to restart the process by requesting a new link and starting a new form. In addition, while respondents fill out the form online, to protect the respondent’s privacy, each session will time‑out after 60 minutes of inactivity and will not save any information. The respondent will need to return to the online form with the provided email link to re-submit the HA-4608 if the system times out.

We are submitting this IT Modification is a non-substantive change request to create a submittable PDF for Form HA-86, Request to Withdraw an Appeals Council Request for Review. We intend to implement this submittable PDF in September 2021.

Revisions to the Collection Instrument for the Online Modality

• Change #1: On the first screen for the online HA-86, the respondent must read and acknowledge instructions and the Privacy Act Statement associated with the HA-86.

Justification: The instructions provide key information to the respondent about the Adobe Sign process, as described in the above background information.

• Change #2: The second screen requires the respondent to enter and confirm their email address.

Justification: Once the respondent submits the email address, they will receive an email from Adobe Sign with a secure link to complete the form electronically.

SSA will implement the online HA-86 upon OMB’s approval. Since we are not requiring any additional information, and we are making no substantive changes to the content of the HA-86 other than to adapt it to the new electronic submission method with only minor revisions to the instructions, we expect no change in the current burden information for this collection.

As stated above, we intend to implement the submittable PDF modality in September 2021. Therefore, we are asking OMB to approve this IT Modification request as soon as possible so we can meet our implementation date.

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