Ha-504-op2 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:

Social Security Number:

Wage Earner:

Judge:

Hearing Scheduled:

Hearing Office:

Location of Hearing:

(Check only one)
[ ] I will be available by online video 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:

Date:

[ ] I have recently moved. My new address is:

Form HA-504-OP2 (09-2003) ef (11-2020)

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Area Code and Telephone Number:

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

Sections 205(b)(1), 205(d) and 1631(c) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to acknowledge you will appear at your hearing with an
Administrative Law Judge.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination regarding
benefits eligibility. However, we may use the information for the administration of our programs including
sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans’ Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract
with us).
A complete list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notice 60-0089, entitled Claims Folder System. Additional information about
this and other system of records notices and our programs are available online at www.socialsecurity.gov or at
your local Social Security office.
We may share the information you provide to other health agencies through computer matching programs.
Matching programs compare our records with records kept by other Federal, State or local government
agencies. We use the information from these programs to establish or verify a person’s eligibility for federally
funded or administered benefit programs and for repayment of incorrect payments or delinquent debts under
these programs.
See PRA Attached below

Form HA-504-OP2 (09-2003) ef (11-2020)

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Information Collected During Your Hearing
The information you provide us during your hearing is protected by the Privacy Act of 1974 (5 U.S.C 552a) and
will become part of an agency system of records. As such, we are providing you with advance notice (below)
per section (e)(3) of the Privacy Act, which requires us to provide you with:
•

The legal authority for collecting the information;

•

The purpose(s) for us collecting your information and how we will use it;

•

The effects, if any, should you choose not to provide some or all of the requested information;

•

Information describing to whom we may share your information and for what purposes;

•

The system of records notice(s) that will maintain the information you provide; and

•

A link to our privacy program webpage for additional information.
Privacy Act Statement
Collection and Use of Personal Information
See Revised Privacy Act Statement Attached

Sections 205 and 1631 of the Social Security Act, as amended, allow us to collect this information. Furnishing
us this information is voluntary. However, failing to provide us with all or part of the information may prevent
us from making an accurate and timely decision on the claim.
We will use the information you provide to make a determination regarding the claim for benefits. 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 SSA in the
efficient administration of our programs; and

•

To student volunteers, individuals working under a personal services contract, 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 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) 60-0006,
entitled Storage of Hearing Records: Tape Cassettes, as published in the Federal Register (FR) on November
11, 2006, at 71 FR 1804, and 60-0320, Electronic Disability 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.
See PRA Attached below

Form HA-504-OP2 (09-2003) ef (11-2020)

SSA will insert the following revised Privacy Act and PRA Statements 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.
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.

Information Collected During Your Hearing
The information you provide us during your hearing is protected by the Privacy Act of 1974 (5
U.S.C. 552a) and will become part of an agency system of records. As such, we are providing
you with advance notice (below) per section (e)(3) of the Privacy Act, which requires us to
provide you with:
•

The legal authority for collecting the information;

•

The purpose(s) for us collecting your information and how we will use it;

•

The effects, if any, should you choose not to provide some or all of the requested
information;

•

Information describing to whom we may share your information and for what purposes;

•

The system of records notice(s) that will maintain the information you provide; and

•

A link to our privacy program webpage for additional information.
Privacy Act Statement
Collection and Use of Personal Information

Sections 205 and 1631 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 make a determination regarding the claim for
benefits. 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) 60-0006, Storage of Hearing Records: Tape Cassettes, as published in the Federal
Register (FR) on November 11, 2006, at 71 FR 1804; 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.
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.