HA-504-OP1 Acknowledgement of Receipt (Notice of Hearing)

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: [Claimant Name]

Social Security Number: [Claimant SSN]

Wage Earner:

Judge:

[Wage Earner]

Office conducting the hearing:

Hearing Scheduled: [Hearing Date and Time]
Location of Hearing: [Room]
[Address]

(Check only one)
[ ] I will be available by phone 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:
[ ] I have recently moved. My new address is:

Date:

Area Code and Telephone Number:

Privacy Act Statement
Collection and Use of Personal Information
See Revised Privacy Act Statement Attached

Sections 205(b), 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 acknowledge the hearing appearance, whether in-person or
teleconference, with an Administrative Law Judge. 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 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 600089, 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 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.

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(b), 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 an accurate and timely decision on any claim filed.
We will use the information you provide to acknowledge you will appear at your hearing with an
Administrative Law Judge. We may also share the information for the following purposes,
called routine uses:
•

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. We contemplate disclosing information under this routine use only in
situations in which SSA may enter a contractual or similar agreement with a third
party to assist in accomplishing an agency function relating to this system of records;
and

•

To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for 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
(SORNs) 60-0005, Administrative Law Judge Working File on Claimant Cases, as published in
the Federal Register (FR) on April 29, 2009, at 74 FR 19617; 60-0089, Claims Folder Systems,
as published in the FR on October 31, 2019, at 84 FR 58422; and 60-0320, Electronic Disability
(eDIB) Claim File, as published in the FR on June 4, 2020, at 85 FR 34477. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.