Request for Change in Time/Place of Disability Hearing

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Section 205(b) of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent you from receiving a new time or location for your disability hearing.
We will use the information you provide to determine whether to reschedule a disability hearing
based on good cause, eligibility, and availability. We may also share your information for the
following purposes, called routine uses:
•

To student volunteers, individuals working under a personal services contract, and other
workers who technically do not have the status of Federal employees, when they are
performing work for the Social Security Administration (SSA), as authorized by law, and
they need access to personally identifiable information in SSA records in order to
perform their assigned Agency functions; and

•

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

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) 60-0009, entitled Hearings and Appeals Case Control System, as published in Federal
Register (FR) on October 13, 1982, at 47 FR 45589; and SORN 60-0010, entitled Hearing Office
Tracking System of Claimant Cases, as published in the FR on January 11, 2006, at 71 FR 1806.
Additional information, and a full listing of all our SORNs, is available on our website at
www.ssa.gov/privacy.

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 8 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.