Addendum to the Supporting Statement for 0960-0671

Addendum to the Supporting Statement for Form HA-504,

Acknowledgement of Receipt (Notice of Hearing)

20 CFR 404.938 and 416.1438

OMB No. 0960-0671

Revision to the Collection

We have revised the burden estimate for the HA-504 to incorporate the burden for the time it takes to gather and submit evidence, which was reported separately in the prior OMB package.

We are also including the HA-504-OP1 in this collection. Previously when we made revisions to include the teleconferencing option on the HA-504, we inadvertently left out the version of the form which does not include this option. In order to correct this oversight, we are revising this ICR to include both versions of the form: the HA-504 which includes the teleconferencing option and the HA-504-OP1 which does not. The HA-504-OP1 is the more commonly used form while the HA-504 is only used for about 10% of all hearings.

There are no other changes to the form. Rather, there is only one variation between the two versions and that is the absence or presence of the check box for the video teleconferencing hearing option.

Upon approval of the HA-504-OP1, SSA’s Forms Management Team will format both forms so that they are standardized like all of our other forms and so that they contain the most current PRA Statement.