Form HA-4633 Claimant's Work Background

Form HA-4633 (XX-2023) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0300

CLAIMANT'S WORK BACKGROUND
A. To be completed by Hearing Office
(Claimant and Social Security Number) (Wage Earner and Social Security Number)
(Leave blank if same as claimant)

The last time we brought your case
up-to-date was:

B. To be completed by Claimant
PLEASE PRINT
Start with your most recent job, and list that and any work performed within the past 5 years.
DATES OF EMPLOYMENT
(APPROXIMATELY)

NAME OF EMPLOYER AND
LOCATION OF EMPLOYMENT

FROM
TO

FROM
TO

FROM
TO

FROM
TO

If more space is needed, use additional sheets.

DUTIES PERFORMED

Form HA-4633 (XX-2023) UF

Page 2 of 2

Privacy Statement
Collection and Use of Personal Information
Sections 205(a), 702, 1631(e)(1), and 1869(b)(1)(C) 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 an accurate and timely decision on any claim filed.
We will use the information you provide to determine benefits eligibility. 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 our programs; and
• To specified business and other community members and Federal, State, and local agencies for
verification of eligibility for benefits under section 1631(e) of the Social Security Act.
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 Notices (SORN)
60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on October 31,
2019, at 84 FR 58422, and 60-0320, Electronic Disability Claim File, as published in the FR on June 4,
2020, at 85 FR 34477. 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 control number. We estimate
that it will take about 20 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find
your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also
listed under U. S. Government agencies in your telephone directory or you may call Social Security
at 1-800-772-1213 (TTY 1-800-325-0778). You may send 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. Send only comments relating to our time estimate to this address, not the
completed form.