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Federal forms, ICRs, and supporting documents

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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 202206-0960-008 · OMB 0960-0710.

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Form
Form
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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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.pdf No   Paper Only
Form HA-86 Request to Withdraw an Appeals Council Request for Review HA-86 - Current.pdf No   Paper Only
Form and Instruction e85 (Submittable PDF) Request to Withdraw a Hearing Request e85 Screen Package - Revised.pdf www.ssa.gov Yes Yes Fillable Fileable Signable
Form and Instruction e86 (Submittable PDF) Request to Withdraw an Appeals Council Request for Review e86 Screen Package - Revised.pdf www.ssa.gov Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

 

1,606 0
   
Individuals or Households
 
   0 %

  Requested 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
HA-85 - Current HA-85 - Current.pdf 09/07/2022
HA-86 - Current HA-86 - Current.pdf 09/07/2022
e85 Screen Package - Current e85 Screen Package - Current.pdf 09/07/2022
e86 Screen Package - Current e86 Screen Package - Current.pdf 09/07/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.