Form HA-4608 Waiver of Right to Personal Appearance Before an Adminis

Form Approved
OMB No. 0960-0284

Social Security Administration/Office of Disability Adjudication and Review

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 statements 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)

Form HA-4608 (11-2010) ef (11-2010)
Destroy Prior Editions

DATE

PRIVACY ACT NOTICE
See Revised Privacy Act Statement Attached
The Social Security Act (sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1), as appropriate)
authorizes the collection of information on this form. We will use the information you provide to
determine if your claim may be decided without an oral hearing. You do not have to give it, but if you do
not you may not receive benefits under the Social Security Act. We need to get more information to
decide if you are eligible for benefits or if a Federal law requires us to do so. Specifically, we may
provide information to another Federal, State, or local government agency which is deciding your
eligibility for a government benefit or program: or to the Department of Justice to represent the Federal
government in a court suit related to a program administered by the Social Security Administration. We
explain in the Federal Register, these and other reasons why we may use or give out information about
you. If you would like more information, contact any Social Security Office.
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies may
use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
office.
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 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 (11-2010) ef (11-2010)

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
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 heath 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.