Form SSA-765 Response to Notice of Revised Determination

.

TOE 710

.SOCIAl SECURITY ADMINISTRAnON

00 NOT WRlTi INmrsSl"ACE

RESPONSE TO NOTICE OF REVISED DETERMINATION
NAME OF CLAIMANT

SOCIAL SECURITY NUMBER

NAME OF WAGE EARNER OR Self EMPLOVED PERSON (IF
DIFFEReNT FROM CLAIMANT)

SOCIAL SECURITY NUMBER

SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPlETE ONLY IN SUPPLEMENTAl
SECURITY INCOME CASE)

DISABILITY

DWlOOW D

TYPE OF BENEFIT:

DWOAKER

CHILO

o

DlSA8IU1'V

"'
OlUND

, wish to appear at a Disability Hearing (includea represenfative appHI'ingl

DYES

I have additional evidence or information to submit

Om

If;::f..s.· check as many as appropriate:

U

EVIDENCE ATTACHED

D

DCHIlD
DNO
DNO

D I Will FURNISH THE FOllOWING EVIDENCE: (DESCRIBE)

I cannot furnish any or all additional evidence. I heve the following information or sources of evidence to provide:

DvES

I NEED AN INTERPRETER

It ·Ve., • complete
this line
NAME OF RePReSENTATIVE {IF ANYI

REfiRESENTATlVE'S ADDReSS

TELEPHONE NUMBEFI
(INClUDE AR£A COOEI

SIGNATURE (FIRST NAME. MIDDLE INITIAL LAST NAME) (WRITE IN INK,

SIGN

........

TELEPHONE NUMBER
(INCLUDE AReA eODEI

HERE ~

MAILING ADDRESS (NUMBER AND STREET. APT. NO., P.O. BOX. OR RURAL ROUTE)
CITY AND STATE

ADDRESS (NUMBER AND STREET. CITY, STATE ZIPCODEI

Form SSA-766 16-89) Use Prior Editions EF 18-20(0)

IZIP CODE

ADDRESS INUMBER AND STREET. CITY. STATE ZIP epOE)

(s. .

information on reversel

PRIVACY ACT NOTICE: The Social Security. Administration is thorized to collect the information on his form
under regulation 20 CFR 404.992 and 416.1492. Giving us e information on this form is volunta~ However, if
you do not respond, we will make a decision based on the vidence in your file.
The Social Security Administration will use the inform ion on this form to fully evaluate your cl
benefits. We may routinely give out the information n this form without your consent if:
1. We need to get more information to decid if you are eligible for benefits;
2. An agency needs this information to de . e if you are eligible for a health or incom rogram such as SSI
State supplementary payments, food amps, Medicaid, energy assistance, Veter s benefits, or Basic
Educational Opportunity Grants;
3. A Federal law requires that we giv out this information;
4. Your Congressman or the Presi nt's office needs this information to answe questions you ask them;
5. Someone needs this informatio to do statistical research or audit reports f us related to the Social
Security programs, or;
6. The Department of Justice eeds the information to represent the Feder Government in a court suit related
to SSA administered pro
These and other reasons wh information about you may be used or give out are explained in the Federal Register.
If you would like more inf
ation about this, get in touch with any So . I Security office.

tement: We may also use the information
give us when we match records by
computer. Matchin rograms compare our records with those of ther Federal, State or local government
agencies. Many a ncies may use matching programs to find or rove that a person qualifies for benefits paid by
the Federal gover ment. The law allows us to do this even if u do not agree to it.
out these and other reasons why informati

about you may be used or given out are available in
is, contact any Social Security office.

RK REDUCTION ACT STATEMENT: The aperwork Reduction Act of 1995 requires us to notify you
that t . Information collection is in accordance w· h the clearance requirements of section 3507 of the Paperwork
Redu tion Act of 1995. We may not conduct or ponsor and you are not required to respond to, a collection of
Inf9'"mation unless it displays a valid OMB con 01 number. We estimate that it will take you about 30 minutes to
c?mplete this form. This includes the time it/ill take to read the instructions, gather the necessary facts and fill
SJut the form.
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Form SSA-7H 16-891 IBackl_EF 18-20001

SSA will insert this new Privacy Act statement in the form at the next scheduled
reprint:
Sections 221, 223, 1611, ofthe Social Security Act, as amended, authorize us to collect
this information. The information is needed to permit the Social Security Administration
(SSA) to make a determination upon your claim. The information you furnish on this
form is voluntary. However, failure to provide all or part of the information requested on
this form will require SSA to use the evidence currently contained in your file to make a
determination.
We rarely use the information you supply for any purpose other than making a
determination upon your claim. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another
person or to another agency in accordance with approved routine uses, which include but
are not limited to: (1) to enable a third party or an agency to assist Social Security in
establishing rights to Social Security benefits and/or coverage; (2) to comply with Federal
laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veteran Affairs); (3) to make
determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; (4) to State agencies to assist in the determination process
for initial and continuing eligibility in their income maintenance programs; (5) to the
Department of Education for determining the eligibility of applicants for Basic
Educational Opportunity Grants; and, (6) to facilitate statistical research, audit or
investigative activities necessary to assure the integrity of Social Security programs.
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. Information from these matching programs can be used to
establish or verify a person's eligibility for Federally-funded and administered benefit
programs and for repayment ofpayments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Record
Notices 60~0050, 60-0089, and 60-0103. The notices, additional information regarding
this form, and information regarding our programs and systems, are available on-line at
www.socialsccurity.gov or at your local Social Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This infonnation 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 control number. We estimate that it will take about 30
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments reladng to our time estimate above to: SSA, 6401 Security Blvd. Baltimore.
MD 21235-6401.