Information Collection

Request for Hearing By Administrative Law Judge--Paper/MCS/MSSICS Versions

IC 9174 under ICR 202412-0960-004 · OMB 0960-0269.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-501 Request for Hearing By Administrative Law Judge Request for Hearing By Administrative Law Judge--Paper/MCS/MSSICS Versions	Form and Instruction
SSI Claims System Appeals Screens in Path Order.pdf	Other-Internal SSI Claims System Scr
MCS Appeals screens - HA-501.docx	Other-Internal MCS Screens
HA-501 Privacy Act Statement (revised).docx	Other-Revised PA and PRA Statements
HA-501 Request for Hearing By Administrative Law Judge HA-501 (revised).pdf	Form and Instruction
HA-501 (current).pdf Current HA-501	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.929 20 CFR 405.722 20 CFR 416.1429 20 CFR 404.1433 20 CFR 418.1350 20 CFR 404.933

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HA-501	No		Paper Only
Other-Internal SSI Claims System Screens		Yes	Yes	Fillable Fileable Signable
Other-Internal MCS Screens		Yes	Yes	Fillable Fileable Signable
Other-Revised PA and PRA Statements		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 162,904

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	162,904	152,579	10,325
Annual IC Time Burden (Hours)	211,775	210,054	1,721
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-501		03/19/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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