HA-55 Objection to Appearing by Video Teleconferencing

Form HA-55 (XX-XXXX)
Discontinue Prior Editions
Social Security Administration

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OMB No.0960-0671

Objection to Appearing by Audio or Agency Video
Claimant's Name:

Social Security Number:

Wage Earner:

Hearing Office:

Completing This Form Is Optional
We will schedule your hearing for the earliest possible date. We will schedule you to attend your hearing in one of the following
ways: (1) by audio using a telephone; (2) by agency video using our video equipment; (3) by online video using a personal
electronic device (such as a smartphone, tablet, or computer); or (4) in person.
You can object to attending your hearing by audio or agency video by completing this form. If you are willing to attend your
hearing by audio or agency video, you do not need to complete this form. We will not schedule you to attend your hearing by
online video unless you agree to attend in that way. We sent you a different form that you can use to tell us that you agree to
attend by online video.
Complete and return this form only if you object to attending your hearing by Audio or Agency Video.
Only complete this section if you do not want to attend your hearing by Audio or Agency Video.
You can check more than one box.
I DO NOT want to attend by Audio (using a telephone) in a private location I choose.
I DO NOT want to attend by Agency Video using agency video equipment in an agency office.
Additional Comments:

Signature:

Date:

Form HA-55 (XX-20XX)

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(b), 205(d) and 1631(c) of the Social Security Act, as amended, allow us to collect this
information, which we will use to acknowledge your decision to object to attending your hearing by audio,
agency video, or both. Providing this information is voluntary, but not providing all or part of the information
may result in us scheduling you to attend a hearing by audio or agency video. As law permits, we may use
and share the information you submit, including with other Federal agencies, contractors, employers, and
others, as outlined in the routine uses within System of Records Notice(s) (SORN) 60-0005, 60-0009,
60-0089, and 60-0320; available at www.ssa.gov/privacy. The information you submit may also be used in
computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup
debts under these programs.

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 5 minutes 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.