This ICR
extension is approved on the condition that the updated burden
estimates are included in the PRA blurb when this form is reprinted
and before the next OMB submission.
Inventory as of this Action
Requested
Previously Approved
12/31/2009
36 Months From Approved
12/31/2006
200
0
200
10
0
10
0
0
0
The SSA-773-U4 is used by claimants or
their representatives to officially wave the right to appear at a
disability hearing. The disability hearing officer uses the signed
form as a basis for not holding a hearing and for preparing a
written decision based solely on the evidence of the record. The
respondents are claimants for disability under Titles II and XVI of
the Social Security Act, or their representatives, who wish to
officially waive their right to appear at a disability
hearing.
Elizabeth Davidson 411-965-0454
liz.davidson@ssa.gov
No
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.