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pdfSocial Security Administration
Form Approved
OMB No. 0960-0348
TOE 710
REQUEST FOR CHANGE IN TIME/PLACE OF DISABILITY HEARING
NAME OF CLAIMANT
(DO NOT WRITE IN THIS SPACE)
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER
SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPLETE ONLY IN SUPPLEMENTAL
SECURITY INCOME CASE)
TYPE OF
BENEFIT:
DISABILITY
WIDOW/
WIDOWER
WORKER
SSI
CHILD
DISABILITY
BLIND
CHILD
NAME OF REPRESENTATIVE, IF ANY
REPRESENTATIVE'S ADDRESS
HEARING CURRENTLY SCHEDULED
DATE
TIME
REQUEST
TELEPHONE NUMBER (INCLUDE
AREA CODE)
PLACE
A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE
A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)
THE REASON FOR MY REQUEST IS:
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
DATE (MONTH, DAY, YEAR)
SIGN
HERE
TELEPHONE NUMBER (INCLUDE
AREA CODE)
MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
ZIP CODE
CITY AND STATE
Witnesses are required ONLY if this form has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the person requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
Form SSA-769-U4 (07-2010) EF (07-2010)
Use old stock
Claims File
Privacy Act Notice
See Revised 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.
COMPUTER MATCHING SYSTEM: We may also use the information you give us when we match
records by computer. Matching programs compare our records with those of other Federal, State or
local government agencies. Many agencies may use matching programs to find or prove that a
person qualifies for benefits paid by the Federal government. The law allows us to do this even if
you do not agree to it.
Explanations about these and other reasons why information about you may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
office.
See Revised PRA
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44
U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take you about 8 minutes to read the instructions, gather
the necessary facts, and answer the questions.
Social Security Administration
Form Approved
OMB No. 0960-0348
TOE 710
REQUEST FOR CHANGE IN TIME/PLACE OF DISABILITY HEARING
NAME OF CLAIMANT
(DO NOT WRITE IN THIS SPACE)
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER
SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPLETE ONLY IN SUPPLEMENTAL
SECURITY INCOME CASE)
TYPE OF
BENEFIT:
DISABILITY
WIDOW/
WIDOWER
WORKER
SSI
CHILD
DISABILITY
BLIND
CHILD
NAME OF REPRESENTATIVE, IF ANY
REPRESENTATIVE'S ADDRESS
HEARING CURRENTLY SCHEDULED
DATE
TIME
REQUEST
TELEPHONE NUMBER (INCLUDE
AREA CODE)
PLACE
A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE
A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)
THE REASON FOR MY REQUEST IS:
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
DATE (MONTH, DAY, YEAR)
SIGN
HERE
TELEPHONE NUMBER (INCLUDE
AREA CODE)
MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
ZIP CODE
CITY AND STATE
Witnesses are required ONLY if this form has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the person requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
Form SSA-769-U4 (07-2010) EF (07-2010)
Use old stock
DHU Copy
Privacy Act Notice
See Revised 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.
COMPUTER MATCHING SYSTEM: We may also use the information you give us when we match
records by computer. Matching programs compare our records with those of other Federal, State or
local government agencies. Many agencies may use matching programs to find or prove that a
person qualifies for benefits paid by the Federal government. The law allows us to do this even if
you do not agree to it.
Explanations about these and other reasons why information about you may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
See Revised PRA
office.
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44
U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take you about 8 minutes to read the instructions, gather
the necessary facts, and answer the questions.
Social Security Administration
Form Approved
OMB No. 0960-0348
TOE 710
REQUEST FOR CHANGE IN TIME/PLACE OF DISABILITY HEARING
NAME OF CLAIMANT
(DO NOT WRITE IN THIS SPACE)
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER
SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPLETE ONLY IN SUPPLEMENTAL
SECURITY INCOME CASE)
TYPE OF
BENEFIT:
DISABILITY
SSI
WIDOW/
WIDOWER
WORKER
CHILD
DISABILITY
BLIND
CHILD
NAME OF REPRESENTATIVE, IF ANY
REPRESENTATIVE'S ADDRESS
HEARING CURRENTLY SCHEDULED
DATE
TIME
REQUEST
TELEPHONE NUMBER (INCLUDE
AREA CODE)
PLACE
A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE
A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)
THE REASON FOR MY REQUEST IS:
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
SIGN
HERE
DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER (INCLUDE
AREA CODE)
MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
ZIP CODE
CITY AND STATE
Witnesses are required ONLY if this form has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the person requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
Form SSA-769-U4 (07-2010) EF (07-2010)
Use old stock
Claimant Copy
Privacy Act Notice
See Revised 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.
COMPUTER MATCHING SYSTEM: We may also use the information you give us when we match
records by computer. Matching programs compare our records with those of other Federal, State or
local government agencies. Many agencies may use matching programs to find or prove that a
person qualifies for benefits paid by the Federal government. The law allows us to do this even if
you do not agree to it.
Explanations about these and other reasons why information about you may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
office.
See Revised PRA
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44
U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take you about 8 minutes to read the instructions, gather
the necessary facts, and answer the questions.
Social Security Administration
Form Approved
OMB No. 0960-0348
TOE 710
REQUEST FOR CHANGE IN TIME/PLACE OF DISABILITY HEARING
NAME OF CLAIMANT
(DO NOT WRITE IN THIS SPACE)
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER
SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPLETE ONLY IN SUPPLEMENTAL
SECURITY INCOME CASE)
TYPE OF
BENEFIT:
DISABILITY
WIDOW/
WIDOWER
WORKER
SSI
CHILD
DISABILITY
BLIND
CHILD
NAME OF REPRESENTATIVE, IF ANY
REPRESENTATIVE'S ADDRESS
HEARING CURRENTLY SCHEDULED
DATE
TIME
REQUEST
TELEPHONE NUMBER (INCLUDE
AREA CODE)
PLACE
A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE
A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)
THE REASON FOR MY REQUEST IS:
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
SIGN
HERE
DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER (INCLUDE
AREA CODE)
MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
ZIP CODE
CITY AND STATE
Witnesses are required ONLY if this form has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the person requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
Form SSA-769-U4 (07-2010) EF (07-2010)
Use old stock
Other
Privacy Act Notice
See Revised 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.
COMPUTER MATCHING SYSTEM: We may also use the information you give us when we match
records by computer. Matching programs compare our records with those of other Federal, State or
local government agencies. Many agencies may use matching programs to find or prove that a
person qualifies for benefits paid by the Federal government. The law allows us to do this even if
you do not agree to it.
Explanations about these and other reasons why information about you may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security
office.
See Revised PRA
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44
U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not
required to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take you about 8 minutes to read the instructions, gather
the necessary facts, and answer the questions.
SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
PRIVACY ACT STATEMENT
Collection and Use of Information
Sections 205, 1631(d)(1), and 1872 of the Social Security Act, as amended, authorize us to
collect this information. We will use this information to track the disposition of hearing
requests.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from rescheduling a hearing.
We rarely use the information for any purpose other than for changing the time/place of a
disability hearing. However, we may use it for the administration and integrity of our programs.
We may also disclose the information to another person or to another agency 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 us in establishing rights to Social Security
benefits and coverage;
2. To comply with Federal laws requiring the release of information from our 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, and investigatory activities necessary to assure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. We use the information from these matching programs to establish or verify a person’s
eligibility for federally-funded and administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act System of
Records Notices entitled, Hearings and Appeals Case Control System, (60-0009) and Hearing
Office Tracking System of Claimant Cases, (60-0010). These notices, and additional
information regarding our programs and systems are available on-line at www.socialsecurity.gov
or at your local Social Security office.
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 (OMB) control number. We estimate that it will take about 8
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-0001.
| File Type | application/pdf |
| File Title | Request For Change in Time/Place of Disability Hearing |
| Subject | Request For Change in Time/Place of Disability Hearing, Change in Time, Disability Hearing, Request for Change in Time of Disabi |
| Author | SSA |
| File Modified | 2013-02-15 |
| File Created | 2010-06-18 |