HA-86 - Current

Form HA-86 (06-2021)
Discontinue Prior Editions
Social Security Administration

REQUEST TO WITHDRAW
AN APPEALS COUNCIL REQUEST FOR REVIEW

Page 1 of 3
OMB No. 0960-0710
Do not write in this space

IMPORTANT NOTICE – This is a request to withdraw your request for review at the
Appeals Council (AC). The AC will consider this request and decide if dismissing your
request for review is appropriate. If the AC denies this request, the appeals process will
go on as if you had not filed this form. If the AC approves this request, the appeals
process will stop. The Administrative Law Judge decision will stay in effect. The
dismissal of the request for review is final and cannot be appealed.
1. CLAIMANT NAME

CLAIMANT SSN

2. WAGE EARNER NAME, IF DIFFERENT (or, if applicable, name of surviving
eligible spouse or other individual eligible to receive benefits due a deceased
claimant)

3. CLAIMANT CLAIM NUMBER, IF
DIFFERENT

4. PRINT YOUR NAME (First name, middle initial, last name)

5. DATE APPEALS COUNCIL
REVIEW REQUESTED
6. DATE OF ALJ DECISION

I wish to withdraw my request for review. My request is voluntary. I understand the effects of this request. Namely, the Appeals
Council may dismiss my request for review. If it does, the Administrative Law Judge decision will stay in effect. This may result in
the potential loss of benefits. The Appeals Council’s dismissal of this request for review is final and cannot be appealed. My
decision affects no other potential parties to my knowledge. I understand that all items relating to my claim will be part
of SSA’s records.
Give reason for withdrawal. (If you need more space, use the reverse of this form.)
_______________________________________________________________________________________________________

SIGNATURE OF PERSON MAKING REQUEST (OPTIONAL)

Continued on reverse
Date (Month, day, year)

Signature (First name, middle initial, last name) (Write in ink)

Telephone Number (Include area code)
Mailing Address (Number And Street, Apt. No., PO Box, Or Rural Route)
City and State

ZIP Code

Enter Name of County (if any) in which you now live

Witnesses are required ONLY if this request has been signed by a mark (X) above. If signed by a mark (X), two witnesses
to the signing, who know the person making the request, must sign below. Both witnesses must give their full address.
1. Signature of Witness

2. Signature of Witness

Address (Number and Street, City, State, ZIP Code)

Address (Number and Street, City, State, ZIP Code)

Form HA-86 (06-2021)

Page 2 of 3
FOR USE OF SOCIAL SECURITY ADMINISTRATION

SSN:

Additional Remarks:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Form HA-86 (06-2021)

Page 3 of 3

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(d)(1), and 1872 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
determination regarding your request to withdraw your request for review at the Appeals Council.
We will use the information you provide to decide if dismissing your request is appropriate. We may also share your information
for the following purposes, called routine uses:
•

To a congressional office in response to an inquiry from that office made at the request of the subject of a record; and

•

To a contractor or other Federal agency to assist in the efficient administration of our 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) 60-0004, entitled Working File
of the Appeals Council, as published in the Federal Register (FR) on April 29, 2009, at 74 FR 19620 and 60-0009, entitled
Hearings and Appeals Case Control System, as published in the FR on October 13, 1982, at 47 FR 45589. 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 10 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.