Waiver of Your Right to Personal Appearance Before a Judge

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Privacy Act Statement Collection and Use of Personal Information
Sections 205(a), 1631(e), and 1869(b) of the Social Security Act, as amended, allow us to collect this information. Furnishing us
this infom,ation is voluntary. However, failing to provide all or part may prevent us fron1 making an accurate and timely decision
on your claim.
We will use the information you provide to continue processing the claim without an oral hearing. We may also share your
infom1ation for the following purposes, called routine uses:
To third party contacts in situations where the party to be contacted has, or is expected to have, infom1ation relating to the
individual's capability to manage his/her affairs or his/her eligibility for or entitlement to benefits under the Social Security
program when the individual is unable to provide information being sought; or the data needed to establish the validity of
evidence or to verify the accuracy of information presented by the individual; and
To contractors and other Federal agencies, as necessary, ·for the purpose of assisting SSA in the efficient administration
of ns programs.
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 benefn 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) 60-0009, entit led Hearing and
Appeals Case Control System, as published in the Federal Register (FR) on October 13, 1982, at 47 FR 45589 and 60-0089,
entitled Claims Folder System, as published in the FR on April 1, 2003, at 68 FR 15784 . Additional infom1a tion, and a full listing of
all of our SORNs, is available on our websne at www.ssa.gov/privacy/.

Paperwork Reduction Act Statement - This infom-.ation collection meets the requirements of 44 U .S.C. § 3507, as amended by
section 2 of the Paperwork Reduction Actof1995 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 5 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 or other aspects of this collection to this address, not the completed form.