One-Time Notice for Pending Claims - HA-55

SOCIAL SECURITY ADMINISTRATION
Refer To: [Clmt SSN]
[Clmt Name]

Office of Disability Adjudication and Review
[Local Office Address]
Tel: [Local Office Phone]/ Fax: [Local office
Fax]
[Current Date]

[OBO Name] on behalf of
[ClaimantFirstName][ClaimantLastName]
[OBO Address]

[ClaimantFirstName][ClaimantLastName]
[ClaimantAddress]

Dear [OBO Name] [Addressee] :
On mm/dd/yy, we are changing our rules regarding the use of video teleconferencing (VTC).
Please read the notice closely.
Use of Video Teleconferencing (VTC) At Your Hearing
In certain situations, we may hold your hearing by VTC rather than in person.
If we schedule your appearance by VTC, you and the ALJ will be at different locations during
the hearing. A large, color monitor will enable you and the ALJ to see, hear, and speak to each
other. The ALJ will also be able to see, hear, and speak to anyone who comes with you to the
hearing. This may include your representative (if you have one), a friend, or a family member.
We will provide someone at your location to run the equipment and provide any other help
you may need.
You must let us know within 30 days after the date you receive this notice if you do not
want to appear at your hearing by VTC. (We may extend this 30-day period if you show
you had good cause for missing the deadline.) Please let us know by completing and
returning the attached form in the envelope we sent [if representative]your
representative[else]you[endif]. We will arrange for you to appear in person.
If you move before we hold your hearing, we retain the right to decide how you will appear at
your hearing, even if you objected to appearing by VTC. For us to consider your change of
residence when we schedule your hearing, you must submit evidence proving your new
residence.

If You Have Any Questions
If you have any questions, please call, (XXX)XXX-XXXX, or write this office. For your
convenience, our address is on the first page of this notice.

Sincerely yours,

Administrative Law Judge

Why You Should Have Your Hearing By Video
If you are getting ready for a hearing before an
administrative law judge, Social Security offers
an efficient method using new technology—video
hearings. With video hearings, we can make the
hearing more convenient for you. Often an
appearance by video hearing can be scheduled
faster than an in-person appearance.

What is a video hearing?
A video hearing allows you and the other
hearing participants to see and hear each other
through large color television screens. The judge
remains in his or her office, and you go to a site
that can be more convenient to where you live. A
technician is there to make sure the equipment
works smoothly.

How is a video hearing scheduled?
If we are using video hearing equipment in your
area, we will contact you to schedule a video
appearance for you at a convenient time. The
judge will consider any preference you may have
expressed for or against appearing by video
teleconferencing when setting the time and place
of your hearing. You will have an opportunity to
object to the set time or place.
If you have any questions or want more
information, please contact your hearing office
when you receive your acknowledgment of your
request for a hearing.

How is a video hearing different?
Except for the equipment, a video hearing is no
different than a hearing at which you appear in
person. The judge can see you and speak with
you and anyone who comes to the hearing with
you, such as your representative or any witnesses.
You can see the judge and anyone who is with the
judge—or anyone at another video teleconference
site, such as a medical or vocational expert.
Transmission of the hearing is secure, and your
privacy is protected. We do not videotape
hearings, but we do make audio recordings—as
we do for all hearings.

What are the advantages of a
video hearing?
Often an appearance by video hearing can be
scheduled faster than an in-person appearance.
That means less waiting time. Also, a video
hearing location may be closer to your home.
That might make it easier for you to have
witnesses or other people accompany you.

www.socialsecurity.gov

Social Security Administration
SSA Publication No. 70-067
ICN 443300
Unit of Issue – HD (one hundred)
October 2004

OBJECTION TO APPEARING BY VIDEO TELECONFERENCING
Name: [Claimant Name]
Social Security Number: [Claimant SSN]
Wage Earner:

[Wage Earner]

Hearing Office: [Hearing Office]

I do not want to appear at my hearing by video teleconference. Please schedule my hearing so
that I may appear in person.
Additional Comments:________________________________________________________________________________________

Signature:

Date:

Area Code and Telephone Number:

Privacy Act Notice Sections 205(a), 205(c)(2) and 233 of the Social Security Act (40 U.S.C. § 405 and 433), and the Federal Records Act of
1950 (64 Stat. 583), authorizes us to collect the information contained on this form. The information you provide will be used to give the
employee credit for the correct amount of wages he or she earned in a given tax year. Completion of this form is voluntary. However, failure to
provide all or part of the requested information may affect the processing of this form and could prevent the employee form acquiring his or her
correct earnings information.
We rarely use this information provided on this form for any other purpose other than for the reasons explained above. However, we may use it
for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. As a quarterly record detail file to provide data in wage investigation cases;
2. As a primary working record file of all SSN holders;
3. To record the latest employer of a wage earner;
4. To provide information to employers/former employers for correcting or reconstructing earnings records and for Social Security tax
purposes; and,
5. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security programs.
This information may be provided to the Internal Revenue Service for tax administration purposes or the Department of Justice for investigating
and prosecuting violations of the Social Security Act. In addition, we may also use this information you provided 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 and administered benefit programs.
A complete list of routine uses for this information is available in Systems of Records Notice, entitled, Earnings Recording and Self-Employment
Income System, Social Security Administration Office of Systems, 60-0059. The notice, additional information regarding this form, and
information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your local Social Security Office.
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 5 minutes to read the instructions, gather the facts, and answer the questions. 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.

Form HA-55 (xx-2014)