Form SSA-769 Request for Change in Time/Place of Disability Hearing

6RFLDO6HFXULW\$GPLQLVWUDWLRQ

)RUP$SSURYHG
20%1R

72(

5(48(67)25&+$1*(,17,0(3/$&(2)',6$%,/,7<+($5,1*

'2127:5,7(,17+,663$&(

3DSHUZRUN$FW3ULYDF\$FW1RWLFH7KHFROOHFWLRQRILQIRUPDWLRQE\XVHRIWKLVIRUPLVDXWKRUL]HG
E\UHJXODWLRQ&)5DQG:KLOH\RXUUHVSRQVHVDUHYROXQWDU\
ZHFDQQRWDFWRQ\RXUUHTXHVWZLWKRXWWKLVLQIRUPDWLRQ,QIRUPDWLRQ\RXIXUQLVKPD\EHGLVFORVHGE\
See below for
WKH6RFLDO6HFXULW\$GPLQLVWUDWLRQWRDQRWKHUSHUVRQRUJRYHUQPHQWDJHQF\RQO\ZLWKUHVSHFWWRVRFLDO
revised Paperwork
VHFXULW\ SURJUDPVDQGWRFRPSO\ZLWK)HGHUDOODZVUHTXLULQJGLVFORVXUHRUH[FKDQJHRILQIRUPDWLRQ
EHWZHHQ66$DQGRWKHUJRYHUQPHQWDJHQFLHV

Reduction Act and
Privacy Act
Statements.

1$0(2)&/$,0$17

1$0(2):$*(($51(5256(/)(03/2<('3(5621

62&,$/6(&85,7<180%(5

63286(
61$0($1'62&,$/6(&85,7<180%(5&203/(7(21/<,16833/(0(17$/
6(&85,7<,1&20(&$6(

',6$%,/,7<

66,

7<3(2)
%(1(),7

:,'2:

:25.(5

:,'2:(5

&+,/'

',6$%,/,7<

%/,1'

&+,/'

1$0(2)5(35(6(17$7,9(,)$1<

5(35(6(17$7,9(
6$''5(66

7(/(3+21(180%(5,1&/8'(
$5($&2'(

+($5,1*&855(17/<6&+('8/('
'$7(

7,0(

3/$&(

$3267(17,7/(0(172)

,
5(48(67

$',))(5(173/$&(2)+($5,1*63(&,)<3/$&(

'$<6)5207+(6&+('8/('+($5,1*
'$7(

7+(5($621)250<5(48(67,6

6,*1$785(),5671$0(0,''/(,1,7,$//$671$0(:5,7(,1,1.



6,*1
+(5(

'$7(0217+'$<<($5

7(/(3+21(180%(5,1&/8'(
$5($&2'(

0$,/,1*$''5(66180%(5$1'675((7$371232%2;25585$/5287(

=,3&2'(

&,7<$1'67$7(

:LWQHVVHVDUHUHTXLUHG21/<LIWKLVIRUPKDVEHHQVLJQHGE\PDUN;DERYH,IVLJQHGE\PDUN;WZRZLWQHVVHVWRWKH
VLJQLQJZKRNQRZWKHSHUVRQUHTXHVWLQJUHFRQVLGHUDWLRQPXVWVLJQEHORZJLYLQJWKHLUIXOODGGUHVVHV
6,*1$785(2):,71(66

6,*1$785(2):,71(66





$''5(66180%(5$1'675((7&,7<67$7(=,3&2'(

$''5(66180%(5$1'675((7&,7<67$7(=,3&2'(

)RUP66$8()
8VHROGVWRFN

&ODLPV)LOH

7KH 3DSHUZRUN 5HGXFWLRQ$FW RI  UHTXLUHVXV WRQRWLI\\RXWKDWWKLV
LQIRUPDWLRQFROOHFWLRQLV LQDFFRUGDQFHZLWKWKHFOHDUDQFHUHTXLUHPHQWVRI
See below$FW
for RI   :H PD\ QRW
VHFWLRQ  RI WKH 3DSHUZRUN 5HGXFWLRQ
revised Paperwork
FRQGXFWRUVSRQVRUDQG\RXDUHQRWUHTXLUHGWRUHVSRQGWRDFROOHFWLRQRI
Reduction
Act and
LQIRUPDWLRQ XQOHVV LW GLVSOD\V D YDOLG 20% FRQWURO
QXPEHU  :H HVWLPDWH
Privacy
Act
WKDWLWZLOOWDNH\RXDERXWPLQXWHVWRFRPSOHWHWKLVIRUP7KLVLQFOXGHV
Statements.
WKHWLPHLWZLOOWDNHWRUHDGWKHLQVWUXFWLRQVJDWKHUWKHQHFHVVDU\IDFWVDQG
ILOORXWWKHIRUP

6RFLDO6HFXULW\$GPLQLVWUDWLRQ

)RUP$SSURYHG
20%1R

72(

5(48(67)25&+$1*(,17,0(3/$&(2)',6$%,/,7<+($5,1*

'2127:5,7(,17+,663$&(

3DSHUZRUN$FW3ULYDF\$FW1RWLFH7KHFROOHFWLRQRILQIRUPDWLRQE\XVHRIWKLVIRUPLVDXWKRUL]HGE\
UHJXODWLRQ&)5DQG:KLOH\RXUUHVSRQVHVDUHYROXQWDU\ZH
FDQQRWDFWRQ\RXUUHTXHVWZLWKRXWWKLVLQIRUPDWLRQ,QIRUPDWLRQ\RXIXUQLVKPD\EHGLVFORVHGE\WKH
See below for
6RFLDO 6HFXULW\ $GPLQLVWUDWLRQ WR DQRWKHU SHUVRQ RU JRYHUQPHQW DJHQF\ RQO\ ZLWK UHVSHFW WR VRFLDO
VHFXULW\ SURJUDPV DQG WR FRPSO\ ZLWK )HGHUDO ODZV UHTXLULQJ
RU H[FKDQJH RI LQIRUPDWLRQ
revisedGLVFORVXUH
Paperwork
EHWZHHQ66$DQGRWKHUJRYHUQPHQWDJHQFLHV

Reduction Act and
Privacy Act
Statements.

1$0(2)&/$,0$17

1$0(2):$*(($51(5256(/)(03/2<('3(5621

62&,$/6(&85,7<180%(5

63286(
61$0($1'62&,$/6(&85,7<180%(5&203/(7(21/<,16833/(0(17$/
6(&85,7<,1&20(&$6(

',6$%,/,7<

66,

7<3(2)
%(1(),7

:,'2:

:25.(5

:,'2:(5

&+,/'

',6$%,/,7<

%/,1'

&+,/'

1$0(2)5(35(6(17$7,9(,)$1<

5(35(6(17$7,9(
6$''5(66

7(/(3+21(180%(5,1&/8'(
$5($&2'(

+($5,1*&855(17/<6&+('8/('
'$7(

7,0(

3/$&(

$3267(17,7/(0(172)

,
5(48(67

$',))(5(173/$&(2)+($5,1*63(&,)<3/$&(

'$<6)5207+(6&+('8/('+($5,1*
'$7(

7+(5($621)250<5(48(67,6

6,*1$785(),5671$0(0,''/(,1,7,$//$671$0(:5,7(,1,1.



6,*1
+(5(

'$7(0217+'$<<($5

7(/(3+21(180%(5,1&/8'(
$5($&2'(

0$,/,1*$''5(66180%(5$1'675((7$371232%2;25585$/5287(

=,3&2'(

&,7<$1'67$7(

:LWQHVVHVDUHUHTXLUHG21/<LIWKLVIRUPKDVEHHQVLJQHGE\PDUN;DERYH,IVLJQHGE\PDUN;WZRZLWQHVVHVWRWKH
VLJQLQJZKRNQRZWKHSHUVRQUHTXHVWLQJUHFRQVLGHUDWLRQPXVWVLJQEHORZJLYLQJWKHLUIXOODGGUHVVHV
6,*1$785(2):,71(66

6,*1$785(2):,71(66





$''5(66180%(5$1'675((7&,7<67$7(=,3&2'(

$''5(66180%(5$1'675((7&,7<67$7(=,3&2'(

)RUP66$8()
8VHROGVWRFN

'+8&RS\

7KH 3DSHUZRUN 5HGXFWLRQ$FW RI  UHTXLUHVXV WRQRWLI\\RXWKDWWKLV
LQIRUPDWLRQFROOHFWLRQLV LQDFFRUGDQFHZLWKWKHFOHDUDQFHUHTXLUHPHQWVRI
VHFWLRQ  RI WKH 3DSHUZRUN 5HGXFWLRQ
$FWforRI   :H PD\ QRW
See below
FRQGXFWRUVSRQVRUDQG\RXDUHQRWUHTXLUHGWRUHVSRQGWRDFROOHFWLRQRI
revised Paperwork
Act and
LQIRUPDWLRQ XQOHVV LW GLVSOD\V D YDOLGReduction
20% FRQWURO
QXPEHU  :H HVWLPDWH
Privacy
Act
WKDWLWZLOOWDNH\RXDERXWPLQXWHVWRFRPSOHWHWKLVIRUP7KLVLQFOXGHV
Statements.
WKHWLPHLWZLOOWDNHWRUHDGWKHLQVWUXFWLRQVJDWKHUWKHQHFHVVDU\IDFWVDQG
ILOORXWWKHIRUP

6RFLDO6HFXULW\$GPLQLVWUDWLRQ

)RUP$SSURYHG
20%1R

72(

5(48(67)25&+$1*(,17,0(3/$&(2)',6$%,/,7<+($5,1*

'2127:5,7(,17+,663$&(

3DSHUZRUN$FW3ULYDF\$FW1RWLFH7KHFROOHFWLRQRILQIRUPDWLRQE\XVHRIWKLVIRUPLVDXWKRUL]HGE\
UHJXODWLRQ&)5DQG:KLOH\RXUUHVSRQVHVDUHYROXQWDU\ZH
FDQQRWDFWRQ\RXUUHTXHVWZLWKRXWWKLVLQIRUPDWLRQ,QIRUPDWLRQ\RXIXUQLVKPD\EHGLVFORVHGE\WKH
6RFLDO 6HFXULW\ $GPLQLVWUDWLRQ WR DQRWKHU SHUVRQ RUSee
JRYHUQPHQW
belowDJHQF\
for RQO\ ZLWK UHVSHFW WR VRFLDO
VHFXULW\ SURJUDPV DQG WR FRPSO\ ZLWK )HGHUDO ODZV UHTXLULQJ GLVFORVXUH RU H[FKDQJH RI LQIRUPDWLRQ
revised Paperwork
EHWZHHQ66$DQGRWKHUJRYHUQPHQWDJHQFLHV

Reduction Act and
Privacy Act
Statements.

1$0(2)&/$,0$17

1$0(2):$*(($51(5256(/)(03/2<('3(5621

62&,$/6(&85,7<180%(5

63286(
61$0($1'62&,$/6(&85,7<180%(5&203/(7(21/<,16833/(0(17$/
6(&85,7<,1&20(&$6(

',6$%,/,7<

66,

7<3(2)
%(1(),7

:,'2:

:25.(5

&+,/'

:,'2:(5

',6$%,/,7<

%/,1'

&+,/'

1$0(2)5(35(6(17$7,9(,)$1<

5(35(6(17$7,9(
6$''5(66

7(/(3+21(180%(5,1&/8'(
$5($&2'(

+($5,1*&855(17/<6&+('8/('
'$7(

7,0(

3/$&(

$3267(17,7/(0(172)

,
5(48(67

$',))(5(173/$&(2)+($5,1*63(&,)<3/$&(

'$<6)5207+(6&+('8/('+($5,1*
'$7(

7+(5($621)250<5(48(67,6

6,*1$785(),5671$0(0,''/(,1,7,$//$671$0(:5,7(,1,1.



6,*1
+(5(

'$7(0217+'$<<($5

7(/(3+21(180%(5,1&/8'(
$5($&2'(

0$,/,1*$''5(66180%(5$1'675((7$371232%2;25585$/5287(

=,3&2'(

&,7<$1'67$7(

:LWQHVVHVDUHUHTXLUHG21/<LIWKLVIRUPKDVEHHQVLJQHGE\PDUN;DERYH,IVLJQHGE\PDUN;WZRZLWQHVVHVWRWKH
VLJQLQJZKRNQRZWKHSHUVRQUHTXHVWLQJUHFRQVLGHUDWLRQPXVWVLJQEHORZJLYLQJWKHLUIXOODGGUHVVHV
6,*1$785(2):,71(66

6,*1$785(2):,71(66





$''5(66180%(5$1'675((7&,7<67$7(=,3&2'(

$''5(66180%(5$1'675((7&,7<67$7(=,3&2'(

)RUP66$8()
8VHROGVWRFN

&ODLPDQW&RS\

7KH 3DSHUZRUN 5HGXFWLRQ$FW RI  UHTXLUHVXV WRQRWLI\\RXWKDWWKLV
LQIRUPDWLRQFROOHFWLRQLV LQDFFRUGDQFHZLWKWKHFOHDUDQFHUHTXLUHPHQWVRI
VHFWLRQ  RI WKH 3DSHUZRUN 5HGXFWLRQ $FW RI   :H PD\ QRW
See below for
FRQGXFWRUVSRQVRUDQG\RXDUHQRWUHTXLUHGWRUHVSRQGWRDFROOHFWLRQRI
revised Paperwork
LQIRUPDWLRQ XQOHVV LW GLVSOD\V D YDOLG 20%
FRQWURO
 :H HVWLPDWH
Reduction
ActQXPEHU
and
WKDWLWZLOOWDNH\RXDERXWPLQXWHVWRFRPSOHWHWKLVIRUP7KLVLQFOXGHV
Privacy Act
WKHWLPHLWZLOOWDNHWRUHDGWKHLQVWUXFWLRQVJDWKHUWKHQHFHVVDU\IDFWVDQG
Statements.
ILOORXWWKHIRUP

6RFLDO6HFXULW\$GPLQLVWUDWLRQ

)RUP$SSURYHG
20%1R

72(

5(48(67)25&+$1*(,17,0(3/$&(2)',6$%,/,7<+($5,1*

'2127:5,7(,17+,663$&(

3DSHUZRUN$FW3ULYDF\$FW1RWLFH7KHFROOHFWLRQRILQIRUPDWLRQE\XVHRIWKLVIRUPLVDXWKRUL]HGE\
See below for revised
UHJXODWLRQ&)5DQG:KLOH\RXUUHVSRQVHVDUHYROXQWDU\ZH
FDQQRWDFWRQ\RXUUHTXHVWZLWKRXWWKLVLQIRUPDWLRQ,QIRUPDWLRQ\RXIXUQLVKPD\EHGLVFORVHGE\WKH
Paperwork
Reduction
6RFLDO 6HFXULW\ $GPLQLVWUDWLRQ WR DQRWKHU
SHUVRQ RU JRYHUQPHQW
DJHQF\ RQO\ ZLWK UHVSHFW WR VRFLDO
VHFXULW\ SURJUDPV DQG WR FRPSO\ ZLWKAct
)HGHUDO
ODZV
UHTXLULQJAct
GLVFORVXUH RU H[FKDQJH RI LQIRUPDWLRQ
and
Privacy
EHWZHHQ66$DQGRWKHUJRYHUQPHQWDJHQFLHV

Statements.

1$0(2)&/$,0$17

1$0(2):$*(($51(5256(/)(03/2<('3(5621

62&,$/6(&85,7<180%(5

63286(
61$0($1'62&,$/6(&85,7<180%(5&203/(7(21/<,16833/(0(17$/
6(&85,7<,1&20(&$6(

',6$%,/,7<

66,

7<3(2)
%(1(),7

:,'2:

:25.(5

:,'2:(5

&+,/'

',6$%,/,7<

%/,1'

&+,/'

1$0(2)5(35(6(17$7,9(,)$1<

5(35(6(17$7,9(
6$''5(66

7(/(3+21(180%(5,1&/8'(
$5($&2'(

+($5,1*&855(17/<6&+('8/('
'$7(

7,0(

3/$&(

$3267(17,7/(0(172)

,
5(48(67

$',))(5(173/$&(2)+($5,1*63(&,)<3/$&(

'$<6)5207+(6&+('8/('+($5,1*
'$7(

7+(5($621)250<5(48(67,6

6,*1$785(),5671$0(0,''/(,1,7,$//$671$0(:5,7(,1,1.



6,*1
+(5(

'$7(0217+'$<<($5

7(/(3+21(180%(5,1&/8'(
$5($&2'(

0$,/,1*$''5(66180%(5$1'675((7$371232%2;25585$/5287(

=,3&2'(

&,7<$1'67$7(

:LWQHVVHVDUHUHTXLUHG21/<LIWKLVIRUPKDVEHHQVLJQHGE\PDUN;DERYH,IVLJQHGE\PDUN;WZRZLWQHVVHVWRWKH
VLJQLQJZKRNQRZWKHSHUVRQUHTXHVWLQJUHFRQVLGHUDWLRQPXVWVLJQEHORZJLYLQJWKHLUIXOODGGUHVVHV
6,*1$785(2):,71(66

6,*1$785(2):,71(66





$''5(66180%(5$1'675((7&,7<67$7(=,3&2'(

$''5(66180%(5$1'675((7&,7<67$7(=,3&2'(

)RUP66$8()
8VHROGVWRFN

2WKHU

7KH 3DSHUZRUN 5HGXFWLRQ$FW RI  UHTXLUHVXV WRQRWLI\\RXWKDWWKLV
LQIRUPDWLRQFROOHFWLRQLV LQDFFRUGDQFHZLWKWKHFOHDUDQFHUHTXLUHPHQWVRI
See below for revised
VHFWLRQ  RI WKH 3DSHUZRUN 5HGXFWLRQ $FW RI   :H PD\ QRW
Paperwork Reduction Act
FRQGXFWRUVSRQVRUDQG\RXDUHQRWUHTXLUHGWRUHVSRQGWRDFROOHFWLRQRI
and Privacy Act Statements.
LQIRUPDWLRQ XQOHVV LW GLVSOD\V D YDOLG 20% FRQWURO QXPEHU  :H HVWLPDWH
WKDWLWZLOOWDNH\RXDERXWPLQXWHVWRFRPSOHWHWKLVIRUP7KLVLQFOXGHV
WKHWLPHLWZLOOWDNHWRUHDGWKHLQVWUXFWLRQVJDWKHUWKHQHFHVVDU\IDFWVDQG
ILOORXWWKHIRUP

SSA will insert the following revised PRA Statement into the form 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 15
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.

Request for Change in Time/Place of Disability Hearing-Form-SSA-769

Privacy Act Statement
Collection and Use of Personal Information
Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended, and 20 C.F.R
Parts 404.907-404.921, and 416.1407-416.1421, authorize us to collect this information.
The purpose of collecting this information is to track hearing office workload from the
receipt of a request for a hearing until the final hearing level disposition. Your response is
voluntary. However, failure to provide the requested information may prevent you from
receiving a new time or place of the hearing.
We rarely use the information provided on this form for any purpose other than for
changing the time/place of disability hearing. In accordance with 5 U.S.C.§ 552a(b) of
the Privacy Act, however, we may disclose the information provided on this form in
accordance with approved routine uses, which include but are not limited to the
following:
1) To enable a third party or an agency to assist Social Security in establishing rights
to Medicare benefits or coverage;
2) To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department
of Veterans Affairs);
3) To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4) To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of Medicare programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally-funded or administered benefits programs and for
repayment of payments or delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used
are available in Systems of Record Notice (SORN) 60-0009 (Hearings and Appeals Case
Control System, SSA, Office of Disability Adjudication and Review) and SORN 60-0010
(Hearing Office Tracking System of Claimant Cases, SSA, Office of Disability
Adjudication and Review). The notices, additional information about this form, and any
other information regarding our systems and programs are available on-line
at www.socialsecurity.gov or at your local Social Security office.