HA-56 Agreement to Appearing by Online Video

Form HA-56 (xx-xxxx)
Social Security Administration

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OMB No. 0960-0671

AGREEMENT TO APPEARING BY ONLINE VIDEO
Claimant's Name
Social Security Number:
Wage Earner:
Hearing Office:

Complete and return this form only if you agree to
attend your hearing by Online Video.
If you agree to attend your hearing by Online Video, please check the following box and provide your email address:
I AGREE to attend my hearing by Online Video using Microsoft Teams and a personal electronic device (such as a
smartphone, tablet, or computer with an internet connection) in a private location I choose. This location must be 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. I also agree to the Social Security Administration using the email address(es)
included below for scheduling the online video hearing.
Your Email Address:
Representative's Email Address:
Additional Comments:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Signature:

Date:

Form HA-56 (xx-xxxx)

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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 contact you for your online video hearing, and acknowledge your agreement to attend your hearing by online video.
Providing this information is voluntary, but not providing all or part of the information will prevent us from scheduling you to attend
your hearing by online 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.