Currently Approved HA-55

OBJECTION TO APPEARING BY VIDEO TELECONFERENCING
Name: [Claimant Name]
Social Security Number: [Claimant SSN]
Wage Earner:

[Wage Earner]

Hearing Office: [Hearing Office]

I do not want to appear at my hearing by video teleconference. Please schedule my hearing so
that I may appear in person.
Additional Comments:________________________________________________________________________________________

Signature:

Date:

Area Code and Telephone Number:

Privacy Act Notice Sections 205(a), 205(c)(2) and 233 of the Social Security Act (40 U.S.C. § 405 and 433), and the Federal Records Act of
1950 (64 Stat. 583), authorizes us to collect the information contained on this form. The information you provide will be used to give the
employee credit for the correct amount of wages he or she earned in a given tax year. Completion of this form is voluntary. However, failure to
provide all or part of the requested information may affect the processing of this form and could prevent the employee form acquiring his or her
correct earnings information.

See Revised Privacy Act Statement Attached

We rarely use this information provided on this form for any other purpose other than for the reasons explained above. However, we may use it
for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. As a quarterly record detail file to provide data in wage investigation cases;
2. As a primary working record file of all SSN holders;
3. To record the latest employer of a wage earner;
4. To provide information to employers/former employers for correcting or reconstructing earnings records and for Social Security tax
purposes; and,
5. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security programs.
This information may be provided to the Internal Revenue Service for tax administration purposes or the Department of Justice for investigating
and prosecuting violations of the Social Security Act. In addition, we may also use this information you provided in computer matching
programs. Matching programs compare our records with records kept by other Federal, State or local government agencies. Information from
these matching programs can be used to establish or verify a person’s eligibility for Federally-funded and administered benefit programs.
A complete list of routine uses for this information is available in Systems of Records Notice, entitled, Earnings Recording and Self-Employment
Income System, Social Security Administration Office of Systems, 60-0059. The notice, additional information regarding this form, and
information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your local Social Security Office.
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
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.

Form HA-55 (4-2015)

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 us from completing the hearing process.
We will use the information to acknowledge you are opting-out of a hearing appearance via
video teleconferencing. 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.