HA-86 - Current

Form Approved
SOCIAL SECURITY ADMINISTRATION/OFFICE OF DISABILITY ADJUDICATION AND REVIEW
OMB No.0960-0710
Do not write in this space

REQUEST TO WITHDRAW
AN APPEALS COUNCIL REQUEST FOR REVIEW

IMPORTANT NOTICE – This is a request to withdraw your request for review at the
Appeals Council (AC). The AC will consider this request and decide if dismissing your
request for review is appropriate. If the AC denies this request, the appeals process will go
on as if you had not filed this form. If the AC approves this request, the appeals process
will stop. The Administrative Law Judge decision will stay in effect. The dismissal of the
request for review is final and cannot be appealed.
1. CLAIMANT NAME
CLAIMANT SSN
2. WAGE EARNER NAME, IF DIFFERENT (or, if applicable, name of surviving eligible 3. CLAIMANT CLAIM NUMBER,
spouse or other individual eligible to receive benefits due a deceased claimant)
IF DIFFERENT

4. PRINT YOUR NAME (First name, middle initial, last name)

5. DATE APPEALS COUNCIL
REVIEW REQUESTED

6. DATE OF ALJ DECISION
I wish to withdraw my request for review. My request is voluntary. I understand the effects of this request. Namely, the Appeals
Council may dismiss my request for review. If it does, the Administrative Law Judge decision will stay in effect. This may result in
the potential loss of benefits. The Appeals Council’s dismissal of this request for review is final and cannot be appealed. My
decision affects no other potential parties to my knowledge. I understand that all items relating to my claim will be part of
SSA’s records.

Give reason for withdrawal. (If you need more space, use the reverse of this form.)

SIGNATURE OF PERSON MAKING REQUEST (OPTIONAL)

Date (Month, day, year)

Signature (First name, middle initial, last name) (Write in ink)

SIGN
HERE
Mailing Address (Number And Street, Apt. No., PO Box, Or Rural Route)
City and State

Continued on reverse

ZIP Code

Telephone Number (Include area code)

Enter Name of County (if any) in which you now live

Witnesses are required ONLY if this request has been signed by a mark (X) above. If signed by a mark (X), two witnesses
to the signing, who know the person making the request, must sign below. Both witnesses must give their full address.
1. Signature of Witness

2. Signature of Witness

Address (Number and Street, City, State, ZIP Code)

Address (Number and Street, City, State, ZIP Code)

Form HA-86 (12-2013)

Page 1

FOR USE OF SOCIAL SECURITY ADMINISTRATION
SSN:

Additional Remarks:

Form HA-86 (12-2013)

Page 2

Privacy Act Statement
Collection and Use of Personal Information
Sections 205 and 1631(d)(1) of the Social Security Act, as amended, allow us to collect this information.
We will use the information you provide to decide if dismissing your request for review is appropriate.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may not allow us to make a correct determination regarding your request to withdraw your request for
review at the Appeals Council.
We rarely use the information you supply for any purpose other than to decide if dismissing your review is
appropriate. However, we may use the information for the administration of our programs including sharing
information:
1.

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); and,

2.

To facilitate statistical research, audit, or investigative 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).

A complete list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notices 60-0004, entitled, Working File of the Appeals Council and 60-0009,
entitled, Hearings and Appeals Case Control System. Additional information about these and other system
of records notices and our programs are available from our Internet website at www.socialsecurity.gov or at
your local Social Security office.
We may share the information you provide to other health agencies through 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 or administered benefit programs and for repayment of incorrect payments or delinquent
debts under these programs.
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.

Form HA-86 (12-2013)

Page 3