Current HA-504

Form Approved
OMB NO. 0960-0671

ACKNOWLEDGEMENT OF RECEIPT (NOTICE OF HEARING)

(COMPLETE THIS FORM AND RETURN IT AT ONCE IN THE ENVELOPE PROVIDED. NO POSTAGE IS NECESSARY)

Claimant:

Social Security Number:

Wage Earner:

Administrative Law Judge:

Hearing Scheduled:

Hearing Office:

Location of Hearing:

(Check only one)
[ ] I will be available by phoneby online video at the time shown on the Notice of Hearing. If an emergency
arises after I mail this form and I am not available, I will immediately notify you at the telephone number shown on the Notice of
Hearing.
[ ] I cannot be present at the time shown on the Notice of Hearing. I request that you reschedule my hearing because:

NOTE: YOUR REQUEST FOR HEARING MAY BE DISMISSED IF YOU DO NOT ATTEND THE HEARING AND CANNOT GIVE
A GOOD REASON FOR NOT ATTENDING. THE TIME OR PLACE OF THE HEARING WILL BE CHANGED IF YOU HAVE A
GOOD REASON FOR YOUR REQUEST.
Signature:

Date:

[ ] I have recently moved. My new address is:

Form HA-504-OP1 (09-2003) ef (03-2015)

See Next Page

Area Code and Telephone Number:

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b)(1), 205(d) and 1631(c) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to acknowledge you will appear at your hearing with an
Administrative Law Judge.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination regarding
benefits eligibility. 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 ensure 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 Notice 60-0089, entitled Claims Folder System. Additional information about
this and other system of records notices and our programs are available online 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 30 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments regarding this burden estimate or any other aspect of this collection, including suggestions for
reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401

Form HA-504-OP1 (09-2003) ef (03-2015)