Form HA-510 Waiver of Written Notice of Hearing

Form HA-510 (07-2017) UF
Discontinue Prior Editions
Social Security Administration

Waiver of Timely Written Notice of Hearing

In the case of:

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OMB No.0960-0671

Claim for:

(Claimant)
(Wage Earner)(Leave blank if same as above)

(Social Security Number)

Under 20 CFR 404.938 and/or 20 CFR 416.1438, where applicable, I am entitled to receive a [20/75] day advance
written notice of the hearing in my case. Having been fully advised of such right, I hereby waive the [20/75] day
advance notice requirement.

(Signature)
(Street Address)
(City, State, and Zip Code)
(Area Code and Telephone Number)
Date:

_________________________

Form HA-510 (07-2017) UF

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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, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us
from completing the hearing process.
We will use the information to document your waiver of rights to receive the written Notice of Hearing. We may
also share your information for the following purposes, called routine uses:
1.

To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security
Administration (SSA) in the efficient administration of its programs; and

2.

To student volunteers and other workers, who technically do not have the status of Federal employees,
when they are performing work for the SSA as authorized by law, and they need access to personally
identifiable information in SSA records in order to perform their assigned agency functions.

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 Notices (SORN) 60-0005, entitled
Administrative Law Judge Working File on Claimant Cases and 60-0089, entitled Claims Folders Systems.
Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.
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 5
minutes to read the instructions, gather the facts, and answer the questions. 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.