Current HA-504

Form Approved
OMB NO. 0960-0671

Social Security Administration

ACKNOWLEDGEMENT OF RECEIPT (NOTICE OF HEARING)

(COMPLETE THIS FORM AND RETURN IT AT ONCE IN THE ENVELOPE PROVIDED. NO POSTAGE IS NECESSARY)
Claimant:

Social Security Number:

Wage Earner:

Administrative Law Judge:

Hearing Scheduled:

Hearing Office:

Location of Hearing:

(Check only one)
I will be present at the time and place shown on the Notice of Hearing. If an emergency arises after I mail this form
and I cannot be present, I will immediately notify you at the telephone number shown on the Notice of Hearing.
I will be available by phone at the time shown on the Notice of Hearing. If an emergency arises after I mail this form
and I am not available, I will immediately notify you at the telephone number shown on the Notice of Hearing.
I do not want to appear at my hearing by video teleconference. Please reschedule my hearing so that I may appear
in person.
I cannot be present at the time and place shown on the Notice of Hearing. I request that you reschedule my
hearing because:

NOTE: YOUR REQUEST FOR HEARING MAY BE DISMISSED IF YOU DO NOT ATTEND THE HEARING AND CANNOT GIVE
A GOOD REASON FOR NOT ATTENDING. THE TIME OR PLACE OF THE HEARING WILL BE CHANGED IF YOU HAVE A
GOOD REASON FOR YOUR REQUEST.
Signature:

I have recently moved. My new address is:

Form HA-504 (01-2013) ef (01-2013)

Date:

Area Code and Telephone Number:

Privacy Act Notice
The Social Security Act (sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869((b)(1) and (c), as appropriate) authorizes the
collection of information on this form. We need the information to continue processing your claim. You do not have to give it, but
if you do not you may not be able to receive benefits under the Social Security Act. We may give out the information on this form
without your written consent if we need to get more information to decide if you are eligible for benefits or if a federal law requires
us to do so. Specifically, we may provide information to another Federal, State, or local government agency which is deciding
your eligibility for a government benefit or program; to the President or a Congressman inquiring on your behalf; to an
independent party who needs statistical information for a research paper or audit report on a Social Security program; or the
Department of Justice to represent the Federal Government in a court suit related to a program administered by the Social
Security Administration.
We may also use the information you give us when we match records by computer. Matching programs compare our records
with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove
that a person qualifies for benefits paid by the federal government. The law allows us to do this even if you do not agree to it.
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 1 minute to read the instructions, gather the facts,
and answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form HA-504 (01-2013) ef (01-2013)