Form SSA-789 Request for Reconsideration – Disability Cessation Right

Form SSA-789 (11-2024) UF
Discontinue Prior Editions
Social Security Administration
REQUEST FOR RECONSIDERATION - DISABILITY CESSATION RIGHT TO APPEAR
(SEE REVERSE SIDE FOR PAPERWORK/PRIVACY ACT NOTICE)
NAME OF CLAIMANT

SOCIAL SECURITY NUMBER

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
(if different from Claimant)

SOCIAL SECURITY NUMBER

Page 1 of 2
OMB No. 0960-0349
FOR SOCIAL SECURITY
OFFICE USE ONLY
(DO NOT WRITE IN
THIS SPACE)
FO Code
Benefit Continuation

SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPLETE ONLY IN
SUPPLEMENTAL SECURITY INCOME CASE)
TYPE OF
BENEFIT

DISABILITY
WORKER

WIDOW

Foreign Language
Notice
SSI

CHILD

DISABILITY

BLIND

CHILD

I DO NOT AGREE WITH THE DETERMINATION TO STOP DISABILITY BENEFITS AND I REQUEST RECONSIDERATION.
My reasons are (reasons should relate to the basis for stopping disability benefits and be as specific as possible):
NOTE: If the notice of the determination on your claim is dated more than 65 days ago, include your reason for not making this
request earlier. Include the date on which you received the notice.

I AM SUBMITTING THE FOLLOWING ADDITIONAL INFORMATION (If "NONE" write "NONE")
(Attach additional page if needed):
I understand that I do not need to provide additional information or evidence to submit this form. I will be able to provide additional
evidence until the date of the hearing. It is preferable that I provide additional information or evidence at the earliest possible time.

CHECK BLOCK 1 AND THE STATEMENTS THAT APPLY OR CHECK BLOCK 2
1. I (and/or my representative) wish to appear at a disability hearing. The disability hearing will be with a person called a
disability hearing officer and it will let me explain why I do not agree with the decision to stop benefits.
I need an interpreter at the disability hearing - Language
(If you need an interpreter, SSA will provide one at no cost to you.)
OR
2. I do not wish to appear nor do I wish a representative to appear for me at the disability hearing and I request that a
decision be made based on the evidence in my case (Complete SSA-773 Waiver of Right to Appear - Disability Hearing)

Form SSA-789 (11-2024) UF

Page 2 of 2

Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in determining a
payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or
continued right to payment, or submits or causes to be submitted any false statement or document knowing the same to contain
any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be
subject to administrative sanctions.
ENTER ADDRESSES FOR BOTH THE CLAIMANT AND REPRESENTATIVE (IF REPRESENTED)
NAME OF CLAIMANT

NAME OF CLAIMANT'S REPRESENTATIVE

STREET ADDRESS

REPRESENTATIVE'S ADDRESS

CITY

STATE ZIP CODE

CITY

STATE ZIP CODE

TELEPHONE NUMBER

DATE

TELEPHONE NUMBER

DATE

Privacy Act Statement
Collection and Use of Personal Information
Sections 205 and 1631(c) of the Social Security Act, as amended, allow us to collect this information, which we will use to
reconsider eligibility for disability benefits. Providing the information is voluntary, but not providing all or part of the information
may prevent us from reconsidering a determination on the claim. As law permits, we may use and share the information you
submit, including with other Federal agencies, contractors, and others, as outlined in the routine uses within System of Records
Notices (SORN) 60-0009, 60-0010, 60-0089, and 60-0320, available at www.ssa.gov/privacy. The information you submit may
also be used in computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup debts
under these programs.

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 13 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.