HA-504-OP1 Acknowledgement of Receipt (Notice of Hearing)

Form HA-504-OP1(04-2024)
Social Security Administration

Page 1 of 3
OMB No. 0960-0671

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:
You will attend by audio, using a telephone, at a private
location of your choice.
The private location you choose must be located
within the 50 states, the District of Columbia, American
Samoa, Guam, the Northern Mariana Islands, the
Commonwealth of Puerto Rico, or the United States
Virgin Islands.
Check Only One
I will be available by telephone 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 cannot attend the hearing at the time shown on the Notice of Hearing. I request that you reschedule my hearing
because:

NOTE: THE ADMINISTRATIVE LAW JUDGE MAY DISMISS YOUR REQUEST FOR HEARING IF NEITHER YOU NOR YOUR
REPRESENTATIVE (IF YOU HAVE ONE) ATTEND THE HEARING AND YOU DO NOT GIVE A GOOD REASON FOR NOT
ATTENDING. IF YOU ASK US TO CHANGE THE TIME OF THE HEARING, WE WILL RESCHEDULE THE HEARING IF YOU
HAVE A GOOD REASON FOR YOUR REQUEST.
Signature:
Date:
Area Code and
Telephone Number:
I have recently moved. My new address is:

Form HA-504-OP1 (04-2024)

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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 you will attend your hearing with an Administrative Law
Judge by audio using a telephone. Providing this information is voluntary, but not providing all or part of the
information may prevent an accurate and timely decision on any claim filed. 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 (OMB) control number. We estimate that it will take about 30 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.

Form HA-504-OP1 (04-2024)

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Information Collected During Your Hearing
The information you provide us during your hearing is protected by the Privacy Act of 1974 (5 U.S.C 552a)
and will become part of an agency system of records. As such, we are providing you with advance notice
(below) per section (e)(3) of the Privacy Act, which requires us to provide you with:
·

The legal authority for collecting the information.

·

The purpose(s) for us collecting your information and how we will use it.

·

The effects, if any, should you choose not to provide some or all of the requested information.

·

Information describing to whom we may share your information and for what purposes.

·

The system of records notice(s) that will maintain the information you provide.

·

A link to our privacy program web page for additional information.

Privacy Act Statement
Collection and Use of Personal Information
Sections 205 and 1631 of the Social Security Act, as amended, allow us to collect this information, which
we will use to make a determination regarding the claim for benefits. Providing this information is voluntary,
but not providing all or part of the information may prevent an accurate and timely decision on the claim. 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) 60-0006 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.