e86 (Submittable P Request to Withdraw an Appeals Council Request for Revie

Application Landing Page:

HA86 Screen Package

3

Email Landing Page:

HA86 Screen Package

4

Email Confirmation Page:

HA86 Screen Package

5

First Email:

HA86 Screen Package

6

HA86 Adobe Form:

HA86 Screen Package

9

HA86 Adobe Form:

HA86 Screen Package

10

HA86 Adobe Form:

HA86 Screen Package

11

HA86 Adobe Form:

HA86 Screen Package

12

HA86 Adobe Form:

HA86 Screen Package

13

HA86 Completion:

HA86 Screen Package

14

Final Email:

HA86 Screen Package

16

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

Sections 205(a), 1631(d)(1), and 1872 of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or
part of the information may prevent us from making an accurate determination regarding your
request to withdraw your request for review at the Appeals Council.
We will use the information you provide to determine if dismissing your request for Appeals
Council review is appropriate. We may also share the information for the following purposes,
called routine uses:
•

To contractors and other Federal agencies, as necessary, for the purpose of assisting
SSA in the efficient administration of its programs. We contemplate disclosing
information under this routine use only in situations in which SSA may enter into a
contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records; 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(s)
(SORN) 60-0004, entitled Working File of the Appeals Council, as published in the Federal
Register (FR) on April 29, 2009, at 74 FR 19620, and 60-0009, entitled Hearings and Appeals
Case Control System, as publish in the FR on October 13, 1982, at 47 FR 45589. Additional
information, and a full listing of all of 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 10 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.