Form SSA-1272-U4 Subpoena--Disability Hearing

Form Approved
OMB No. 0960-0428

SOCIAL SECURITY ADMINISTRATION

SUBPOENA-DISABILITY HEARING
NAME OF CASE

TO:

YOU ARE REQUIRED TO APPEAR A S A WITNESS AT THE DISABILITY HEARING OF THE ABOVE NAMED PERSON. YOU MUST APPEAR
AT THE FOLLOWING TlME AND LOCATION.
DATE OF HEARING

LOCATION OF HEARING

TIME OF HEARING

YOU ARE REQUIRED TO PROVIDE THE FOLLOWING DOCUMENTS IN CONNECTION WITH THE DISABILITY HEARING OF THE ABOVE
NAMED PERSON.

THE DOCUMENTS MUST BE RECEIVED BY

I

-

A T THE FOLLOWING ADDRESS

ADDRESS

DISABILITY HEARING OFFlCERlSUPERVlSORY HEARING OFFICER

DATE

AUTHORIZING OFFICIAL

DATE

I

FORM SSA-1272-U4 (4-84) EF (3-2002)

WITNESS COPY

PAPERWORK REDUCTION ACT STATEMENT:
This information
Paperwork

Form Approved
OMB NO. 0960-0428

SOCIAL SECURITY ADMINISTRATION

SUBPOENA-DISABILITY HEARING
NAME OF CASE

YOU ARE REQUIRED TO APPEAR A S A WITNESS A T THE DISABILITY HEARING OF THE ABOVE NAMED PERSON. YOU MUST APPEAR
A T THE FOLLOWING TlME AND LOCATION.
DATE OF HEARING

LOCATION OF HEARING

TIME OF HEARING

YOU ARE REQUlREiD TO PROVIDE THE FOLLOWING DOCUMENTS IN CONNECTION WITH THE DISABILITY HEARING OF THE ABOVE
NAMED PERSON.

THE DOCUMENTS MUST BE RECEIVED BY

I

-

A T THE FOLLOWING ADDRESS

ADDRESS

DISABILITY HEARING OFI=ICERISUPERVISORY HEARING OFFICER

DATE

AUTHORIZING OFFICIAL

DATE

FORM S S A - 1 2 7 2 4 4 (4-84) EF (3-2002)

REGIONAL OFFICE COPY

PAPERWORK REDUCTION ACT STATEMENT:

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f C ~ / ~ ' r i 3Tlr?-,
as amended by section 2 of the
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Form Approved
OMB No. 0960-0428

SOCIAL SECURITY ADMINIS'TRATION

SUBPOENA-DISABILITY HEARING
NAME OF CASE

YOU ARE REQUIRED TO APPEAR AS A WITNESS AT THE DISABILITY HEARING OF THE ABOVE NAMED PERSON. YOU MUST APPEAR
AT THE FOLLOWING TlME AND LOCATION.
LOCATION OF HEARING

DATE OF HEARING

TIME OF HEARING

YOU ARE REQUIRED TO PROVIDE THE FOLLOWING DOCUMENTS IN CONNECTION WITH THE DISABILITY HEARING OF THE ABOVE
NAMED'PERSON.

THE DOCUMENTS MUST BE RECEIVED BY

A T THE FOLLOWING ADDRESS

ADDRESS

DISABILITY HEARING 0F:FICERlSUPERVISORY HEARING OFFICER

DATE

AUTHORIZING OFFICIAL

DATE

I

FORM SSA-1272-U4 (4-84) EF (3-2002)

CLAIMS FOLDER COPY

PAPERWORK REDUCTION ACT STATEMENT:

Form Approved
OMB NO. 0960-0428

SOCIAL SECURITY ADMIIVISTRATION

SUBPOENA-DISABILITY HEARING
NAME OF CASE

TO:

YOU ARE.REQUIRED TO APPEAR AS A WITNESS A T THE DISABILITY HEARING OF THE ABOVE NAMED PERSON. YOU MUST APPEAR
A T THE FOLLOWING TlME AND LOCATION.
DATE OF HEARING

LOCATION OF HEARING

TlME OF HEARING

YOU ARE REQUIRED TO PROVIDE THE FOLLOWING DOCUMENTS IN CONNECTION WITH THE DISABILITY HEARING OF THE ABOVE
NAMED PERSON.

THE DOCUMENTS MUST BE RECEIVED BY

A T THE FOLLOWING ADDRESS

ADDRESS

DISABILITY HEARING OFFICERISUPERVISORY HEARING OFFICER

DATE

AUTHORIZING OFFICIAL

DATE

I

FORM S S A - 1 2 7 2 4 4 (4-84) EF (3-2002)

DHU-CONTROL COPY

PAPERWORK REDUCTION ACT STATEMENT:
This information collection

Thefollowing revised PRA Statement will be inserted into theform at its
next scheduled reprinting:
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 control number. We estimate that it will take about 30
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send&o comments relating to our time estimate to this
address, not the completed form.