Download:
pdf |
pdf fJ
Adobe Sign
Options v
Next Required m
Request to Withdraw a Hearin...
-
-
SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW
REQUEST TO WITHDRAW A HEARING REQUEST
IMPORTANT NOTICE - This is a request to withdraw your hearing request. The judge 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 wiU stop. We w�I 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 judge 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 wtith the Appeals Council (AC) within 60 days after you
get the dismissal notice. Even if you do not ask the judge to cancel your request, and do
not file an appeal, the AC may set aside the dismissal of your hearing request. This would
occl.l' within 60 days after we mail the dismissal notice to you.
CLAIMANT NAME
I CLAIMANT SSN
Sta rt
*
Form Approved
0MB No. 0960-0710
Do not write in this space
*
WAGE EARNER NAME, IF DIFFERENT (or, if applicable, name of
surviving eligible spouse or ocher individual eligible co receive benef"ns
due a deceased claimant)
CLAIMANT CLAIM NUMBER, IF DIFFERENT
PRINT YOUR NAME (First name, middle initial, last name)i
DATE OF HEARING
REQUEST
BENEFIT APPLIED
FOR
TYPE OF CLAIM(S)
I wish to withdraw my hearing request. My request is volunta,y. I understand the effects of this request NamelY, a judge may dismiss
my hearing request. If the judge 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 recoms.
Give reason for withdrawal. (If you need more space, use the reverse of this form.)
*
0 Continued on reverse
SIGNATURE OF PERSON MAKING REQUEST ( OPTIONAL)
Date (Month, day, year)
Signature (First name, middle initial, last name) (Write in ink)
*
SIGN Click here to sign
HERE
Mailing Address (Number And Street. Apt. No.• PO Box. Or Rural Route)
*Teleohone Number f/nc/ude area codel
*
Enter Name of County (if any) in which you now live
ZIP Code
City and State
*
*
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
2. Signature of Witness
Address (Number and Street, City, State, ZIP Code)
Address (Number and Street, City, State, ZIP Code)
Form HA-85 (01-2014)
Page 1
w
Language I English: US
1
13
--
8
(±)
.!,
© 2021 Adobe. All rights reserved.
X
Terms Consumer Disclosure Trust Cookle preferences
fJ
Adobe Sign
Options v
Required fields completed
Request to Withdraw a Heari...
-
-
SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW
REQUEST TO WITHDRAW A HEARING REQUEST
IMPORTANT NOTICE - This is a request to withdraw your hearing request. The judge 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 judge 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 CouncH (AC) within 60 days after you
get the dismissal notice. Even if you do not ask the judge 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
I CLAIMANT SSN
Test Claimant
Form Approved
0MB No. 0960-0710
Do not write in this space
123456789
WAGE EARNER NAME, IF DIFFERENT (or, if applicable, name of
surviving eligible spouse or ocher individual eligible ro receive benef'rcs
due a deceased claimant)
CLAIMANT CLAIM NUMBER, IF DIFFERENT
PRINT YOUR NAME (First name, m iddle initial, last name)
Test Claimant
DATE OF HEARING
REQUEST
01/01/2020
Additional Name
123123A
BENEFIT APPLIED
FOR
Test
TYPE OF CLAIM(S)
Test
I wish to withdraw my hearing request. My request is voluntary. I understand the effects of this request. Name!y, a judge may dismiss
my hearing request. If the judge 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, u se the reverse of this form.)
Test Information
0
Continued on reverse
SIGNATURE OF PER SON MAKING REQUEST (OPT IONAL)
Date (Month, day, year)
Signature (First name, middle initial, last name) (Write in ink)
Jun 7, 2021
SIGN
Teleohone Number flnclude area codel
HERE Test Claimant (Jun 7, 2021)
+11112223333
Mailing Address (Number And Street. Apt. No .• PO Box. Or Rural Route)
123 Test Street
Enter Name of County (if any) in which you now live
ZIP Code
City and State
Test
11111
Test cta.LMaMt
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
2. Signature of Witness
Address (Number and Street, City, State, ZIP Code)
Address (Number and Street, City, State, ZIP Code)
Form HA-85 (01-2014)
Page 1
By signing, I agree to both this agreement and the c '",,. ''','r ,; ,, ,,,.r,'. My use ofAdobe
Sign isgovemed by the ,',cf, ,r,,, T,,r•n,,", "'·
Click to Sign
$
fJ
Adobe Sign
Request to Withdraw a Heari...
Options v
Required fields completed
SSN:
123456789
Additional Remarks:
FOR USE OF SOCIAL SECURITY ADMINISTRATION
0
APPROVED
O NOT APPROVED
BECAUSE
O
TITLE
-
Form HA-85 (01-2014)
0 WITHDRAWAL
WOULD
HARM INTEREST OF
CLAIMANT OR OTHER
PARTIES
CLAIMANT DOES
UNDERSTAND
CONSEQUENCES
0 JUDGE
.
s,gn ,sgovemed by the A,/,,�,, T,'l"'c
(Attach explanation)
O OTHER (Specify)
Page2
By signing, I agree to both this agreement and the L,'"'" "','/ ,'!.,, ,,,,"1,0 My use ofAdobe
.
O OTHER
•
,, ',,,_
.
C1.1ck to Sign
$
Mon 5/17/2021 3:49 PM
Social Security Administration
[EXTERNAL] Request to Withdraw a Hearing Request has been Signed and Filed
To
Claimant Email Address·
Retention Policy
Delete_7_Year_Default (7 years)
8 If there are problems with how this message is displayed, click here to view it in a web browser.
Expires
5/15/2028
You're done signing
Request to Withdraw a Hearing Request
Open Document
The document is complete.
You can open the final document to review its activity history or download a copy for reference.
For additional security, you have set a pass-..vord for this document. You -..vill need the pass\vord to review this document. If you forgot or lose the password, it
cannot be reset.
This link is personalized for you and, for security purposes, we recommend you do NOT fonvard/share this email or link -..vith others. If you DO fonvard/share this
email or link with others, you accept the risk that, by sharing your personal information, the person assisting you may misuse your personal information. If you have
any questions about this email or feel that you received this in error, please contact SSA at 1-800-772-1213 (TIY 1-800-325-0778) between 8:00 am-7:00 pm,
Monday through Friday.
The document is fully executed. The Social Security Adroioi�ation has control over the retention period for this document which determines the amount of time it
will be available for download from Adobe Sign. Adobe recommends that you save a local copy of this fully-executed document for your records.
■
AdobeSlgn
Need your own docmne:nts •�ed? Adobe Sigii cm help save you time. Leana mott.
To ensure that you continue receiving our em.u1s, please .add ad�d�roa to your addre35 book or safe li.3t.
© 2019 Adobe. All rights reserred.
fJ Adobe Sign
Iii
Sign In
SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW
Form Approved
0MB No. 0960-0710
REQUEST TO WITHDRAW A HEARING REQUEST
IMPORTANT NOTICE - This is a request to withdraw your hearing request. The judge 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 judge 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 judge 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.
Request to Withdraw a Hearing Request
Created Jun 07, 2021 2:58 PM
Do not write in this space
From: Social Security Administration
(no-reply@)ssa.gov)
Status: Signed
Message: THIS LINK EXPIRES IN FIVE (S)
CALENDAR DAYS. You have a document to
review and sign. You can access the
CLAIMANT SSN
CLAIMANT NAME
Test Claimant
WAGE EARNER NAME, IF DIFFERENT (or, if applicable, name of
surviving eligible spouse or other individual eligible to receive benefits
due a deceased claimant)
123456789
security, you were required to set a password
in order to review the document. If vou forget
CLAIMANT CLAIM NUMBER, IF DIFFERENT
Additional Name
123123A
PRINT YOUR NAME (First name, middle initial, last name)
DA TE OF HEARING
REQUEST
Test Claimant
document using the link above. For additional
See more
Actions
BENEFIT APPLIED
FOR
Test
01/01/2020
TYPE OF CLAIM(S)
Test
I wish to withdraw my hearing request. My request is voluntary. I understand the effects of this request. Namely, a judge may dismiss
my hearing request. If the judge 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.)
Test Information
SIGNATURE OF PERSON MAKING REQUEST (OPTIONAL)
Rrt Clai111al!t
sIGN
HERE Test Claimant (Jun 7, 202115:12 EDT)
Mailing Address (Number And Street, Apt. No., PO Box, Or Rural Route)
ZIP Code
City and State
Test
Download PDF
Jb
Download Audit Report
�
Add Notes
>
1 Recipient (1 Completed)
>
Activity
Continued on reverse
Date (Month, day, year)
Signature (First name, middle initial, last name) (Write in ink)
123 Test Street
D
�
11111
Jun 7, 2021
Telephone Number (Include area code)
+ 11112223333
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
2. Signature of Witness
Address (Number and Street, City, State, ZIP Code)
Address (Number and Street, City, State, ZIP Code)
Form HA-85 (01-2014)
Page 1
....
Q[�,
Language I English: US
/3['
�[.!.�
© 2021 Adobe. All rights reserved.
Terms Consumer Disclosure Trust Cookie preferences
fJ
Iii
Sign In
Adobe Sign
SSN:
...
123456789
Request to Withdraw a Hearing Request
Created Jun 07, 2021 2:58 PM
Additional Remarks:
From: Social Security Administration
(no-reply@)ssa.gov)
Status: Signed
Message: THIS LINK EXPIRES IN FIVE (S)
CALENDAR DAYS. You have a document to
review and sign. You can access the
document using the link above. For additional
security, you were required to set a password
in order to review the document. If vou forget
See more
Actions
�
Download PDF
Fl,
Download Audit Report
�
Add Notes
>
1 Recipient (1 Completed)
>
Activity
FOR USE OF SOCIAL SECURITY ADMINISTRATION
0
APPROVED
O NOT APPROVED
BECAUSE
O
CLAIMANT DOES
UNDERSTAND
CONSEQUENCES
TITLE
Form HA-85 (01-2014)
0 WITHDRAWAL
WOULD
HARM INTEREST OF
CLAIMANT OR OTHER
PARTIES
0 JUDGE
O OTHER
(Attach explanation)
O OTHER (Specify)
Page 2
...
0[�2
Language I English: US
/3['
�[.!..4z,
© 2021 Adobe. All rights reserved.
Terms Consumer Disclosure Trust Cookie preferences
| File Type | application/pdf |
| File Modified | 2021-06-16 |
| File Created | 2021-05-17 |