Form SSA-789 Request for Reconsideration--Disability Cessation

Form SSA-789 (05-2024) UF
Discontinue Prior Editions
Social Security Administration
REQUEST FOR RECONSIDERATION - DISABILITY CESSATION RIGHT TO APPEAR
(SEE REVERSE SIDE FOR PAPERWORK/PRIVACY ACT NOTICE)
NAME OF CLAIMANT

SOCIAL SECURITY NUMBER

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
(if different from Claimant)

SOCIAL SECURITY NUMBER

Page 1 of 2
OMB No. 0960-0349
FOR SOCIAL SECURITY
OFFICE USE ONLY
(DO NOT WRITE IN
THIS SPACE)
FO Code
Benefit Continuation

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

DISABILITY
WORKER

WIDOW

Foreign Language
Notice
SSI

CHILD

DISABILITY

BLIND

CHILD

I DO NOT AGREE WITH THE DETERMINATION TO STOP DISABILITY BENEFITS AND I REQUEST RECONSIDERATION.
My reasons are (reasons should relate to the basis for stopping disability benefits and be as specific as possible):
NOTE: If the notice of the determination on your claim is dated more than 65 days ago, include your reason for not making this
request earlier. Include the date on which you received the notice.

I AM SUBMITTING THE FOLLOWING ADDITIONAL INFORMATION (If "NONE" write "NONE")
(Attach additional page if needed):
We are adding the following language to
the box:

I understand that I do not need to provide
additional information or evidence to submit
this form. I will be able to provide additional
evidence until the date of the hearing. It is
preferable that I provide additional
information or evidence at the earliest
possible time.
CHECK BLOCK 1 AND THE STATEMENTS THAT APPLY OR CHECK BLOCK 2
1. I (and/or my representative) wish to appear at a disability hearing. The disability hearing will be with a person called a
disability hearing officer and it will let me explain why I do not agree with the decision to stop benefits.
I need an interpreter at the disability hearing - Language
(If you need an interpreter, SSA will provide
no cost
tolanguage
you.)
We one
are at
revising
the
to:
I
do
not
wish
to
appear
nor
do
I wish a
OR
representative
to
appear
for
me
at the
2. I do not wish to appear nor do I wish a representative to appear for me at the
disability hearing. I have been
disability
hearing
and
I
request
that
advised of my right to have a disability hearing. I understand that a disability hearing awill give me a chance to present
decision
be made
ondisability
the
witnesses. It will also let me explain to the disability
hearing
officerbased
why my
benefits should not end. I
evidence
in
my
case
(Complete
SSA-773
understand that this chance to be seen and heard could help the disability hearing
officer learn about the facts in my
Waiver
of Right
to Appear
Disability
case. The disability hearing officer would give me
a chance
to have
people-who
know about my condition give
Hearing)
information and explain how my condition keeps me from working and restricts my activities. I have been told about my
right to representation at the disability hearing, including representation by an attorney or other person of my choice.
Although the above has been explained to me, I do not want to appear at a disability hearing, or have someone
represent me at a disability hearing. I prefer to have the disability hearing officer decide my case on the evidence in my
file, plus any evidence that I submit or that may be obtained by the Social Security Administration. I have been advised
that if I change my mind, I can request a disability hearing prior to the writing of a decision in my case. In this case, I can
make the request with any Social Security office.

Form SSA-789 (05-2024) UF

Page 2 of 2

Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in determining a
payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or
continued right to payment, or submits or causes to be submitted any false statement or document knowing the same to contain
any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be
subject to administrative sanctions.
ENTER ADDRESSES FOR BOTH THE CLAIMANT AND REPRESENTATIVE (IF REPRESENTED)
NAME OF CLAIMANT

NAME OF CLAIMANT'S REPRESENTATIVE

STREET ADDRESS

REPRESENTATIVE'S ADDRESS

CITY

STATE ZIP CODE

CITY

STATE ZIP CODE

TELEPHONE NUMBER

DATE

TELEPHONE NUMBER

DATE

Privacy Act Statement
Collection and Use of Personal Information

We are revising the
Act Statement
Section 205(b) of the Social Security Act, as amended, allows us to collect this information. Furnishing usPrivacy
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, or could result in loss of benefits.
We will use the information you provide to determine a substitute party and pursue an appeal on behalf of a deceased claimant.
We may also share your information for the following purposes, called routine uses:
• 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 us, as authorized by law, and they need access to personally
identifiable information (PII) in our records in order to perform their assigned agency functions; and
• To contractors and other Federal Agencies, as necessary, for the purpose of assisting us in the efficient administration of our
programs. We will disclose information under this routine use only in situations in which we may enter into a contractual or similar
agreement with a third party to assist in accomplishing an SSA function relating to this system of records.
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) 60-0089, entitled Claims
Folders System, as published in the Federal Register (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 our SORNs is, available on our website at www.ssa.gov/privacy.
We are revising the
Paperwork Reduction Act Statement 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 5 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