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Federal forms, ICRs, and supporting documents

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 202206-0960-008 · OMB 0960-0710.

Documents and Forms

Documents and forms in this information collection
Document NameDocument 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
Form HA-85
Request to Withdraw a Hearing Request 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
Form HA-86
Request to Withdraw an Appeals Council Request for Review 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
Form e85 (Submittable P
Request to Withdraw a Hearing Request 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 and Instruction
Form e86 (Submittable P
Request to Withdraw an Appeals Council Request for Review 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 and Instruction
HA-85 Request to Withdraw a Hearing Request
HA-85 - Current.pdf 		Form
HA-86 Request to Withdraw an Appeals Council Request for Revie
HA-86 - Current.pdf 		Form
e85 (Submittable P Request to Withdraw a Hearing Request
e85 Screen Package - Revised.pdf 		Form and Instruction
e86 (Submittable P Request to Withdraw an Appeals Council Request for Revie
e86 Screen Package - Revised.pdf 		Form and Instruction
HA-85 - Current.pdf
HA-85 - Current		IC Document
HA-86 - Current.pdf
HA-86 - Current		IC Document
e85 Screen Package - Current.pdf
e85 Screen Package - Current		IC Document
e86 Screen Package - Current.pdf
e86 Screen Package - Current		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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.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

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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

Documents for IC
table that charts IC Documents
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.