Form HA-L90 Request to Show Cause for Failure to Appear

Form Approved
OMB No. 0960-0794

Social Security Administration
Office of Disability Adjudication and Review

Date:

REQUEST TO SHOW CAUSE FOR FAILURE TO APPEAR
Claimant:

Wage Earner:

Social Security Claim Number:

NOTE: Please read the PRIVACY ACT statement on the reverse page and the statements below.
You requested a hearing with an administrative law judge (ALJ). We scheduled a hearing for you
at

for

.

You did not come to your hearing or contact us to explain why you could not attend.
If you still want an ALJ to hold a hearing on your claim, you may explain in writing why you did not
come to your hearing. You may print, write, or type your explanation in the space provided. You may
include another page if you need more space. Attach all supporting documentation. You must send
your explanation to us within 10 days from the date of this notice.
An ALJ will review your explanation. The ALJ will use rules in the Code of Federal Regulations to
decide if your explanation shows that you had a good reason for missing your hearing.

• If the ALJ decides that you had a good reason for missing your hearing, we will schedule
another hearing for you.

• If the ALJ decides that you did not have a good reason for missing your hearing, and your
representative also did not come to your hearing, the ALJ may dismiss your request for a
hearing.

• If the ALJ decides that you did not have a good reason for missing your hearing, but your

representative came to your hearing, the ALJ may decide your claim based on the evidence
in your file.
I did not come to the hearing because:

Mail your explanation to: Office of Disability Adjudication and Review,
If you have any questions, you may call
SIGNATURE OF CLAIMANT (OR AUTHORIZED REPRESENTATIVE)

DATE

HA-L90 (04-2013)

Privacy Act Statement
Collection of Personal Information
Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended authorize us to collect
this information. We will use this information to evaluate your reason for failing to appear at your
scheduled hearing.
Please See Revised Privacy Act Statement Attached
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
requested information may affect our ability to re-evaluate the decision on your claim.
We rarely use the information you supply for any purpose other than for determining problems in
Social Security programs. 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 the following:
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 the Department of Veterans'
Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs
as at the Federal, State, and local level; and
4. 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 or administered benefit programs and for repayment of payments or delinquent
debts under these programs.
A complete use of routine uses for this information is available in our Systems of Records Notices,
60-0009, Hearings and Appeals Case Control System, and 60-0010, Hearing Office Tracking System
of Claimant Cases. These notices, additional information regarding our programs and systems, are
available on-line at www.socialsecurity.gov or at any local 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 (OMB) control
number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and
answer the questions. Send only comments relating to our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401.

HA-L90 (04-2013)