20 CFR 404.971 and 416.1471 (Request to Withdraw a Hearing Request; Request to Withdraw an Appeals Council Request for Review)

SSA will insert the following revised Privacy Act Statement into the form
as soon as possible:
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 205(a), 1631(d)(1), and 1872 of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent us from making an accurate
determination regarding your request to withdraw your request for a hearing.
We will use the information you provide to decide if dismissing your hearing request is
appropriate. We may also share your information for the following purposes, called
routine uses:
1. To a congressional office in response to an inquiry from that office made at
the request of the subject of a record.
2. To a contractor or other Federal agency to assist in the efficient
administration of our programs.
In addition, we may share this information in accordance with the Privacy Act and other
Federal laws. For example, where authorized, we may use and disclose this information
in computer matching programs, in which our records are compared to other records to
establish or verify a person’s eligibility for Federal benefit programs and for repayment
of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices,
60-0005, entitled Administrative Law Judge Working File on Claimant Cases, and 600009, entitled Hearings and Appeals Case Control System. Additional information and a
full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.