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pdfSocial Security Administration
Form Approved
OMB No. 0960-0348
TOE 710
REQUEST FOR CHANGE IN TIME/PLACE OF DISABILITY HEARING
(DO NOT WRITE IN THIS SPACE)
NAME OF CLAIMANT
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
X
DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER
(INCLUDE AREA CODE)
MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
CITY AND STATE
ZIP CODE
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
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.
See Revised Privacy Act Statement Attached
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 Statement Attached
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
TELEPHONE NUMBER (INCLUDE
AREA CODE)
REPRESENTATIVE'S ADDRESS
HEARING CURRENTLY SCHEDULED
DATE
TIME
REQUEST
PLACE
A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)
A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE
THE REASON FOR MY REQUEST IS:
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
SIGN
HERE
X
DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER
(INCLUDE AREA CODE)
MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
CITY AND STATE
ZIP CODE
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
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.
See Revised Privacy Act Statement Attached
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 Statement Attached
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
TELEPHONE NUMBER (INCLUDE
AREA CODE)
REPRESENTATIVE'S ADDRESS
HEARING CURRENTLY SCHEDULED
DATE
TIME
PLACE
A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)
A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE
REQUEST
THE REASON FOR MY REQUEST IS:
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
SIGN
HERE
X
DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER
(INCLUDE AREA CODE)
MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
CITY AND STATE
ZIP CODE
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
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.
See Revised Privacy Act Statement Attached
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 Statement Attached
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
TELEPHONE NUMBER (INCLUDE
AREA CODE)
REPRESENTATIVE'S ADDRESS
HEARING CURRENTLY SCHEDULED
DATE
TIME
REQUEST
PLACE
A DIFFERENT PLACE OF HEARING (SPECIFY PLACE)
A POSTENTITLEMENT OF
DAYS FROM THE SCHEDULED HEARING
DATE
THE REASON FOR MY REQUEST IS:
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)
SIGN
HERE
X
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
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.
See Revised Privacy Act Statement Attached
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 Statement Attached
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 and PRA Statements into the form as soon as
possible:
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Section 205(b) of the Social Security Act, as amended, allows us to collect this information. We
will use the information you provide to attempt to reschedule a disability hearing based on
good cause, eligibility, and availability.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent you from receiving a new time or place of the hearing.
We rarely use the information you supply for any purpose other than what we state above,
however, we may use the information for the administration of our programs, including sharing
information:
1. 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);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census
and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notices, 60-0009, entitled Hearings and Appeals Case Control
System, and 60-0010, entitled Hearing Office Tracking System of Claimant Cases. Additional
information about these and other system of records notices and our programs is available
from our Internet website at www.socialsecurity.gov or at your local Social Security office.
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. Information from these matching programs can be used to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
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 20 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 21235-6401.
| 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 |
| Author | SSA |
| File Modified | 2015-11-18 |
| File Created | 2015-11-18 |