Current SSA-765

Form SSA-765 (09-2019)
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0347
DO NOT WRITE IN THIS
SPACE

RESPONSE TO NOTICE OF REVISED DETERMINATION
NAME OF CLAIMANT

SOCIAL SECURITY NUMBER

NAME OF WAGE EARNER OR SELF EMPLOYED
PERSON (IF DIFFERENT FROM CLAIMANT)

SOCIAL SECURITY NUMBER

SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPLETE ONLY IN
SUPPLEMENTAL SECURITY INCOME CASE)
SSI

DISABILITY
TYPE OF BENEFIT:

WORK

WIDOW

CHILD

DISABILITY

BLIND

CHILD

I wish to appear at a Disability Hearing (includes representative appearing)

YES

NO

I have additional evidence or information to submit

YES

NO

If "Yes," check as many as appropriate:
EVIDENCE ATTACHED

I WILL FURNISH THE FOLLOWING EVIDENCE: (DESCRIBE)

I cannot furnish any or all additional evidence. I have the following information or sources of evidence to provide:

YES

I NEED AN INTERPRETER
LANGUAGE
If "Yes," complete this line
NAME OF REPRESENTATIVE (IF ANY)

CHECK
ONE

REPRESENTATIVE'S ADDRESS

NO

SSA NEEDS TO PROVIDE INTERPRETER
I WILL PROVIDE INTERPRETER
TELEPHONE NUMBER (INCLUDING
AREA CODE)

SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)

DATE (MONTH, DAY, YEAR)

SIGN
HERE

TELEPHONE NUMBER (INCLUDING
AREA CODE)

MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
CITY AND STATE

ZIP CODE

Witnesses are required ONLY if this form has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing
who know the person requesting reconsideration must sign below, giving their full addresses.

1. SIGNATURE OF WITNESS
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)

2. SIGNATURE OF WITNESS
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)

Form SSA-765 (09-2019)

Page 2 of 2
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a) and 1631(e) 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 making an accurate and
timely decision regarding Social Security benefits.
We will use the information to determine eligibility for benefits. We may also share your information for the following purposes,
called routine uses:
• To third party contacts, where necessary, to establish or verify information provided by representative payees or payee
applicants; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting Social Security Administration in
the efficient administration of its programs.
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) 60-0089, entitled Claims
Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784 and 60-0320, entitled Electronic
Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all
of our SORNs, is available on our website at www.ssa.gov/privacy.

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 relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.