Form HA-4608 "Waiver of Your Right to Personal Appearance Before an Administrative Law Judge"

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Social Security Administration
Form Approved
Office of Disability Adjudication and Review
OMB No. 0960-0284
WAIVER OF YOUR RIGHT TO PERSONAL APPEARANCE
BEFORE AN ADMINISTRATIVE LAW JUDGE
Claimant
Wage Earner (Leave blank if same as claimant)
Social Security Claim Number
NOTE: Please read the PRIVACY ACT statement on reverse and the statements below. Then, print, write, or type your
response to the states in the space provided below. If you need more space, attach a separate page to this form.
• I have been advised of my right to appear in person before an Administrative Law Judge. I understand that my personal
appearance before an Administrative Law Judge would provide me with the opportunity to present written evidence, my
testimony, and the testimony of other witnesses. I understand that this opportunity to be seen and heard could be helpful to the
Administrative Law Judge in making a decision.
• Although my right to a personal appearance before an Administrative Law Judge has been explained to me, I do not want to
appear in person. I want to have my case decided on the written evidence. The reason I do not want to appear in person at a
hearing is:
• I understand that if I do not appear before an Administrative Law Judge, I still have the right to present a written summary of my
case, or to enter written statements about the facts and law material to my case in the record.
• If I change my mind and decide to request a personal appearance before the Administrative Law Judge, I understand that I
should make this request to the Hearing Office before the decision of the Administrative Law Judge is mailed to me.
• I understand that I have a right to be represented and that if I need representation, the Social Security office or hearing office
can give me a list of legal referral and service organizations to assist me in locating a representative.
SIGNATURE OF CLAIMANT (OR AUTHORIZED REPRESENTATIVE)
DATE
Form HA-4608 (07-2014) ef (07-2014)
Destroy Prior Editions
Social Security Administration
Form Approved
Office of Disability Adjudication and Review
OMB No. 0960-0284
WAIVER OF YOUR RIGHT TO PERSONAL APPEARANCE
BEFORE AN ADMINISTRATIVE LAW JUDGE
Claimant
Wage Earner (Leave blank if same as claimant)
Social Security Claim Number
NOTE: Please read the PRIVACY ACT statement on reverse and the statements below. Then, print, write, or type your
response to the states in the space provided below. If you need more space, attach a separate page to this form.
• I have been advised of my right to appear in person before an Administrative Law Judge. I understand that my personal
appearance before an Administrative Law Judge would provide me with the opportunity to present written evidence, my
testimony, and the testimony of other witnesses. I understand that this opportunity to be seen and heard could be helpful to the
Administrative Law Judge in making a decision.
• Although my right to a personal appearance before an Administrative Law Judge has been explained to me, I do not want to
appear in person. I want to have my case decided on the written evidence. The reason I do not want to appear in person at a
hearing is:
• I understand that if I do not appear before an Administrative Law Judge, I still have the right to present a written summary of my
case, or to enter written statements about the facts and law material to my case in the record.
• If I change my mind and decide to request a personal appearance before the Administrative Law Judge, I understand that I
should make this request to the Hearing Office before the decision of the Administrative Law Judge is mailed to me.
• I understand that I have a right to be represented and that if I need representation, the Social Security office or hearing office
can give me a list of legal referral and service organizations to assist me in locating a representative.
SIGNATURE OF CLAIMANT (OR AUTHORIZED REPRESENTATIVE)
DATE
Form HA-4608 (07-2014) ef (07-2014)
Destroy Prior Editions
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(d)(i), 1631(e)(i)(ii), and 1869(b), of the Social Security Act, as amended, authorize us
to collect this information. We will use the information you provide to make a determination on your claim
without an oral hearing.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the requested
information may affect the decision on your claim.
We rarely use the information for any purpose other than for making a decision regarding continuing
entitlement to benefits. However, we may use it for the administration and integrity of our programs. We
may also disclose the information to another person or to another agency in accordance with approved
routine uses, including, but not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to our benefits
and coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and,
4. To facilitate statistical research, audit, and investigatory activities necessary to assure the integrity
and improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies. We use
the information from these programs to establish or verify a person's eligibility for federally funded and
administered benefit programs and for repayment of incorrect payments or delinquent debts under
these programs.
A complete list of routine uses of this information is available in our Privacy Act Systems of Records Notices
entitled, Hearing and Appeals Case Control System, 60-009 and Claims Folders Systems, 60-0089. These
notices, additional information regarding our programs and systems are available on-line at
www.socialsecurity.gov
or at your Social Security office.
- This information collection meets the requirements of 44 U.S.C. §
Paperwork Reduction Act Statement
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 control number. We estimate that it
will take about 2 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 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.
Form HA-4608 (07-2014) ef (07-2014)
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