Request to Show Cause for Failure to Appear - New Claims

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or
part of the information may affect our ability to reevaluate the decision on the benefit eligibility
of the named claimant.
We will use the information to evaluate the reason for failing to appear at the scheduled hearing.
We may also share your information for the following purposes, called routine uses:
1. To a congressional office in response to an inquiry from that office made at the request of
the subject of a record; and
2. To third party contacts in situations where the party to be contacted has, or is expected to
have, information 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. An individual is considered
to be unable to provide certain types of information when he/she is incapable of or
questionable mental capability; he/she cannot read or write; a language barrier exists; or
the data are needed to establish the validity of evidence to verify the accuracy of
information presented by the individual, and it concerns his/her eligibility for benefits
under the Social Security program.
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 benefit 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 Notice
(SORN) 60-0320, entitled Electronic Disability (eDIB) Claim File. Additional information and a
full listing of all our SORNs are available on our website at www.ssa.gov/privacy/sorn.html.