Form HA-510 Waiver of Timely Written Notice of Hearing

Form HA-510 (08-2022) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0671

Waiver of Timely Written Notice of Hearing
In the case of:

Claim for:

(Claimant)

(Wage Earner) (Leave blank if same as above)

(Social Security Number)

Under 20 CFR 404.938 and/or 20 CFR 416.1438, where applicable, I am entitled to receive a 75 day
advance written notice of the hearing in my case. Having been fully advised of such right, I hereby waive
the 75 day advance notice requirement.
I must inform SSA about or submit all evidence known to me that relates to whether or not I am blind or
disabled. I must do this at least 5 business days prior to the date of the hearing. I understand that the
administrative law judge may not accept evidence that I inform SSA about or submit less than 5 days prior to
the hearing unless I provide a good reason.

(Signature)

(Street Address)

(City, State, and Zip Code)

(Area Code and Telephone Number)

Date:

Form HA-510 (08-2022) UF

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b)(1), 205(d), and 1631(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 us from completing the hearing process.
We will use the information to document your waiver of rights to receive the written Notice of Hearing. We
may also share your information for the following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social
Security Administration (SSA) in the efficient administration of its programs; and
2. To student volunteers and other workers, who technically do not have the status of Federal
employees, when they are performing work for SSA as authorized by law, and they need access
to personally identifiable information in SSA records in order to perform their assigned Agency
functions.
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) 60-0005,
entitled Administrative Law Judge Working File on Claimant Cases and 60-0089, entitled Claims Folders
Systems. Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.

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 5 minutes to
read the instructions, gather the facts, and answer the questions. You may send comments on our time
estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to
our time estimate to this address, not the completed form.