Form HA-85 Request to Withdraw a Hearing Request

SOCIAL SECURITY ADMINISTRATION

REQUEST TO WITHDRAW A HEARING REQUEST
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

Form Approved
OMB No. 0960-0710

Do not write in this space

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)

Form HA-85 (01-2014)

2.

Signature of Witness

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

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SSN:
Additional Remarks:

FOR USE OF SOCIAL SECURITY ADMINISTRATION
APPROVED

NOT APPROVED
BECAUSE

SIGNATURE OF SSA EMPLOYEE

Form HA-85 (01-2014)

CLAIMANT DOES
NOT
UNDERSTAND
CONSEQUENCES

TITLE

Page 2

WITHDRAWAL WOULD
HARM INTEREST OF
CLAIMANT OR OTHER
PARTIES

ADMINISTRATIVE
LAW JUDGE

OTHER (Specify)

OTHER
(Attach
explanation)

DATE

Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy
Act Statement Attached

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 60-0009, 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.
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-85 (01-2014)

Page 3

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:
•

To a congressional office in response to an inquiry from that office made at the request of
a subject of a record; and

•

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 with 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
(SORN) 60-0005, entitled Administrative Law Judge Working File on Claimant Cases, as
published in the FR on April 29, 2009, at 74 FR 19617 and 60-0009, entitled Hearings and
Appeals Case Control System, as published in the FR on October 13, 1982, at 47 FR 45589.
Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

7/3/2019 4:59 PM