COVID-19 Telephone Hearing Agreement Form

Social Security Administration

OMB Control No.0960-0671

COVID-19 Telephone Hearing Agreement Form
Claimant’s Name:
Social Security Number:
Wage Earner:
Representative’s Name:

Due to the coronavirus 2019 (COVID-19) national public health emergency, we are conducting
hearings only by telephone at this time. We will not conduct the hearing by telephone unless the
claimant (hereinafter “you”) voluntarily agrees to appear in that manner. If you, the claimant, agree
to appear at your hearing by telephone, the administrative law judge (ALJ) assigned to your case
will conduct the hearing from his or her personal residence.
Please check one of the boxes below to tell us whether you voluntarily agree to appear at your
hearing by telephone. If you agree to appear by telephone, please be sure to provide the telephone
number where we can reach you at the time of your hearing. If you do not agree to appear by
telephone, we will wait to schedule your hearing until we resume standard operations and can
schedule you to appear at a hearing by video teleconferencing or in person, as appropriate. If we
have already scheduled your hearing and you do not agree to appear by telephone, we will postpone
your hearing.
[ ] I agree to a telephone hearing. On the day of the hearing, I can be contacted at:
My contact number:
My representative’s contact number:

[ ] I do not agree to a telephone hearing. I understand that by selecting this option, my
hearing will be delayed.
If your contact information changes or if you have questions, please call the Hearing Office at
the telephone number on the COVID-19 Public Health Emergency Hearing Changes
notice associated with this request.
Additional Comments:________________________________________________________________________________________

[ ] I am the claimant whose name appears above, and the selection on this form accurately
represents my voluntary determinations.
Claimant Signature:

Date:

---- Or ----

[ ] I represent the claimant whose name appears above and who presently is unable to sign
this form due to COVID-19 precautions. As the authorized representative, I have consulted
with the claimant, and the selection on this form accurately represents his or her voluntary
determinations.
Representative Signature:

Date:

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1631(d)(1) 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 an accurate and timely decision on any claim filed.
We will use the information to schedule your hearing. We may also share your information for
the following purposes, called routine uses:
•

To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representatives or representative payees to the extent necessary to pursue
Social Security claims and to representative payees when the information pertains to
individuals for whom they serve as representative payees, for the purpose of assisting
SSA in administering its representative payment responsibilities under the Act and
assisting the representative payees in performing their duties as payees, including
receiving and accounting for benefits for individuals for whom they serve as payees; and

•

To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA
in the efficient administration of its programs. We contemplate disclosing information
under this routine use only in situations in which SSA may enter a contractual or similar
agreement with a third party to assist in accomplishing an agency function relating to this
system of records.

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 Notice
(SORN) 60-0320, entitled Electronic Disability Claim File, as published in the Federal Register
(FR) on December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all of
our SORNs, is available on our website at www.ssa.gov/privacy/.
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 10 minutes to read the instructions, gather
the facts, and answer the questions. You may send comments regarding this burden estimate or
any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate
to this address, not the completed form.