Form SSA-769 Request for Change in Time/Place of Disability Hearing

Form SSA-769 (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0348

Request for Change in Time/Place of Disability Hearing
Name of Claimant

(DO NOT WRITE IN THIS SPACE)

Name of Wage Earner or Self-Employed Person

Social Security Number

Spouse's Name and Social Security Number
(Complete only if Supplemental Security Income Case)

Disability
Type of Benefit:

Worker

SSI

Widow/Widower

Child

Disability

Blind

Child

Name of Representative, if any

Representative's Address

Telephone Number
(Include area code)

Hearing Currently Scheduled
Date

Request

Time

A postentitlement of
scheduled hearing date

The reason for my request is:

Place

days from the

A different place of hearing (specify place)

Form SSA-769 (XX-XXXX) UF

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Privacy Act Statement
Collection and Use of Personal Information
Section 205(b) of the Social Security Act, as amended, allows us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part of the information may prevent you from
receiving a new time or location for your disability hearing.
We will use the information you provide to determine whether to reschedule a disability hearing based on
good cause, eligibility, and availability. We may also share your information for the following purposes,
called routine uses:
• To student volunteers, individuals working under a personal services contract, and other workers who
technically do not have the status of Federal employees, when they are performing work for the Social
Security Administration (SSA), as authorized by law, and they need access to personally identifiable
information in SSA records in order to perform their assigned Agency functions; 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 (SORN) 60-0009,
entitled Hearings and Appeals Case Control System, as published in Federal Register (FR) on October 13,
1982, at 47 FR 45589; and SORN 60-0010, entitled Hearing Office Tracking System of Claimant Cases, as
published in the FR on January 11, 2006, at 71 FR 1806. Additional information, and a full listing of all 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 8 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.