Form HA-85 Request to Withdraw a Hearing Request

SOCIAL SECURITY ADMINISTRATION/OFFICE OF DISABILITY ADJUDICATION AND REVIEW

REQUEST TO WITHDRAW A HEARING REQUEST

Do not write in this space

IMPORTANT NOTICE - This is a request to withdraw your hearing request. The Administrative
Law Judge (ALJ) will consider this request and decide if dismissing your hearing request is
appropriate. If we deny your request, the hearing process will go on as if you had not filed this
form. If we approve this request, the hearing process will stop. We will send you a dismissal
notice and we will not process your case. The last determination in your case will stay in effect.
If you change your mind, you must ask the ALJ to cancel this request to withdraw within 60
days after you get the dismissal notice. You must give a good reason why the dismissal was
wrong. You may also file an appeal with the Appeals Council (AC) within 60 days after you get
the dismissal notice. Even if you do not ask the ALJ to cancel your request, and do not file an
appeal, the AC may set aside the dismissal of your hearing request. This would occur within 60
days after we mail the dismissal notice to you.
CLAIMANT NAME

CLAIMANT SSN

###-##-####
WAGE EARNER NAME, IF DIFFERENT (or, if applicable, name of surviving eligible
spouse or other individual eligible to receive benefits due a deceased claimant)

CLAIMANT CLAIM NUMBER, IF DIFFERENT

###-##-####
PRINT YOUR NAME (First name, middle initial, last name)

DATE OF HEARING
REQUEST

BENEFIT APPLIED FOR

TYPE OF CLAIM(S)

I wish to withdraw my hearing request. My request is voluntary. I understand the effects of this request. Namely, an ALJ may dismiss my
hearing request. If the ALJ does, the last determination in my case will stay in effect, unless the dismissal is set aside. This may result in the
potential loss of benefits. I understand that I have 60 days from when I get the dismissal notice to cancel my request or file an appeal with the
Appeals Council. My decision affects no other potential parties to my knowledge. I understand that all items relating to my claim will be part of
SSA’s records.

Give reason for withdrawal. (If you need more space, use the reverse of this form.)

Continued on reverse
SIGNATURE OF PERSON MAKING REQUEST (OPTIONAL)
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., PO Box, Or Rural Route)

City and State

ZIP Code

Enter Name of County (if any) in which you now live

Witnesses are required ONLY if this request has been signed by a mark (X) above. If signed by a mark (X), two witnesses to the
signing, who know the person making the request, must sign below. Both witnesses must give their full address.
1.

Signature of Witness

Address (Number and Street, City, State, ZIP Code)

HA-85

2.

Signature of Witness

Address (Number and Street, City, State, ZIP Code)

SSN:
Additional Remarks:

Will add Privacy Act information once the form is formally approved.

FOR USE OF SOCIAL SECURITY ADMINISTRATION
APPROVED

NOT APPROVED
BECAUSE

SIGNATURE OF SSA EMPLOYEE

CLAIMANT DOES
NOT
UNDERSTAND
CONSEQUENCE
S

WITHDRAWAL
WOULD HARM
INTEREST OF
CLAIMANT OR
OTHER PARTIES

TITLE

DATE
ADMINISTRATIVE
LAW JUDGE

HA-85

OTHER (Attach explanation)

OTHER (Specify)