HA-2 Objection to Video Teleconferencing – Request to Show Ca

Form Approved
OMB 0960-0671

Social Security Administration

Objection to Video Teleconferencing – Request to Show Cause
Claimant

Wage Earner

Social Security Number

You notified us that you do not want to appear by video teleconferencing at your upcoming hearing.
However, you missed the deadline for making that request. The deadline was 30 days after you
received the letter informing you of this right.
An Administrative Law Judge (ALJ) may still approve your request if you can show that you had a
good reason for not responding before the deadline. You may provide us with an explanation in
writing within 10 days from the date of this notice . You may print, write, or type your explanation
in the space provided. You may include another page if you need more space. Attach any supporting
documentation.
An ALJ will review your explanation. The ALJ will use the rules in the Code of Federal Regulations to
decide if your explanation shows that you had a good reason for missing the deadline.
y

If the ALJ decides that you had a good reason for missing the deadline, we will schedule a
hearing for you to appear in person.

y

If the ALJ decides that you did not have a good reason for missing the deadline, we may
schedule a hearing for you to appear by video teleconference.

I did not object on time to appearing by video teleconference because:

Signature

Date

Please mail your explanation to:

NOTE: Please read the PRIVACY ACT statement on the reverse page.

Form HA-2 (XX-XXXX)

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b)(1), 205(d) and 1631(c) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to determine if you have good
cause for not responding to Form HA-55 (Objection to Appearing by Video Teleconferencing)
timely.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. 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 complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0089, entitled Claims Folder System.
Additional information about this and other system of records notices and our programs are
available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through 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 programs 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 10 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.

Form HA-2 (XX-XXXX)