HA-504-OP2 Acknowledgement of Receipt (Notice of Hearing)

Form HA-504-OP2 (xx-xxxx)
Social Security Administration

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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:

Administrative Law Judge:

Hearing Scheduled:

Hearing Office:

Location of Hearing: You will attend by online video, using a
personal electronic device, such as a
smartphone, tablet, or computer with an
internet connection, in a private location of
your choice.
The private location you choose must be
located within the 50 states, the District of
Columbia, American Samoa, Guam, the
Northern Mariana Islands, the
Commonwealth of Puerto Rico, or the
United States Virgin Islands.
(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 attend the hearing at the time shown on the Notice of Hearing. I request that you reschedule my hearing
because:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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NOTE: THE ADMINISTRATIVE LAW JUDGE MAY DISMISS YOUR REQUEST FOR HEARING IF NEITHER YOU NOR YOUR
REPRESENTATIVE (IF YOU HAVE ONE) ATTEND THE HEARING AND YOU DO NOT GIVE A GOOD REASON FOR NOT
ATTENDING. IF YOU ASK US TO CHANGE THE TIME OF THE HEARING, WE WILL RESCHEDULE THE HEARING IF YOU
HAVE A GOOD REASON FOR YOUR REQUEST. IF YOU NO LONGER WANT TO ATTEND THE HEARING BY ONLINE
VIDEO, YOU MUST WITHDRAW YOUR PRIOR AGREEMENT BEFORE THE START OF YOUR HEARING.
Signature:
I have recently moved. My new address is:

Date:

Area Code and Telephone Number:

Form HA-504-OP2 (xx-xxxx)

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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, which we will use
to acknowledge you will attend your hearing with an Administrative Law Judge by online video. Providing this information is
voluntary, but not providing all or part of the information may prevent an accurate and timely decision on any claim filed. As law
permits, we may use and share the information you submit, including with other Federal agencies, contractors, employers, and
others, as outlined in the routine uses within System of Records Notice(s) (SORN) 60-0005, 60-0009, 60-0089, and 60-0320;
available at www.ssa.gov/privacy. The information you submit may also be used in computer matching programs to establish or
verify eligibility for Federal benefit programs and to recoup debts under these programs.
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. 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-504-OP2 (xx-xxxx)

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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.

•

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, which we will use to make a
determination regarding the claim for benefits. Providing this information is voluntary, but not providing all or part of the
information may prevent an accurate and timely decision on the claim. As law permits, we may use and share the information
you submit, including with other Federal agencies, contractors, employers, and others, as outlined in the routine uses within
System of Records Notice(s) (SORN) 60-0006 and 60-0320, available at www.ssa.gov/privacy. The information you submit may
also be used in computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup debts
under these programs.