SSA-773-U4 - Current

Form SSA-773 (02-2022)
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0534

Waiver of Right to Appear - Disability Hearing

(DO NOT WRITE IN THIS SPACE)

Name of Claimant

Name of Wage Earner or Self-Employed

Social Security Number

(COMPLETE ONLY IN SUPPLEMENTAL SECURITY INCOME CASE)
Name of Spouse

Type
of
Benefit

Social Security Number

Disability
Worker

Widow/
Widower

SSI
Child

Disability

Blind

Child

Name of Representative, if any

Representative Address

Telephone Number (Include Area Code)

I have been advised of my right to have a disability hearing. I understand that a hearing will give me an opportunity to present
witnesses and explain in detail to the disability hearing officer, who will decide my case, the reasons why my disability benefits
should not end. I understand that this opportunity to be seen and heard could be effective in explaining the facts in my case, since
the disability hearing officer would give me an opportunity to present and question witnesses and explain how my impairments
prevent me from working and restrict my activities. I have been given an explanation of my right to representation, including
representation at a hearing by an attorney or other person of my choice. Although the above has been explained to me, I do not
want to appear at a disability hearing, or have someone represent me at a disability hearing. I prefer to have the disability hearing
officer decide my case on the evidence of record plus any evidence which I may submit or which may be obtained by the Social
Security Administration. I have been advised that if I change my mind, I can request a hearing prior to the writing of a decision in
my case. In this event, I can make the request with any Social Security office.
Signature (First Name, Middle Initial, Last Name) (Write in ink)

Date (Month, Day, Year)

Telephone Number (Include Area Code)

Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route)

City and State

ZIP Code

Witnesses are required ONLY if this form has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing
who know the person requesting reconsideration must sign below, giving their full addresses.
1. Signature of Witness

2. Signature of Witness

Address (Number and Street, City, State, ZIP Code)

Address (Number and Street, City, State, ZIP Code)

4 copies: Claims File, DHU, Claimant, Other

Form SSA-773 (02-2022)

Page 2 of 2

Privacy Act Statement
Collection and Use of Privacy Information
Sections 205(a) and (b) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of
the information may prevent an accurate and timely decision on your waiver request.
We will use the information you provide to acknowledge your decision to waive the right to a disability
hearing and to determine your waiver eligibility. We may also share the information for the following
purposes, called routine uses:
• To contractors and other Federal Agencies, as necessary, for the purpose of assisting us in the
efficient administration of our programs. We will disclose information under this routine use only in
situations in which we may enter into a contractual or similar agreement to obtain assistance in
accomplishing an SSA function relating to this system of records; and
• To student volunteers, individuals working under a personal services contract, and other workers
who technically do not have the status of Federal Employees, when they are performing work for us,
as authorized by law, and they need access to personally identifiable information (PII) in our records
in order to perform their assigned agency functions.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0005,
entitled Administrative Law Judge Working File on Claimant Cases, as published in the Federal Register
(FR) on April 29, 2009, at 74 FR 19617; and 60-0089, entitled Claims Folders Systems, as published in the
FR on October 31, 2019, at 84 FR 58422. Additional information, and a full listing of all our SORNs, is
available on our website at www.ssa.gov/privacy.

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 3 minutes to read the instructions, gather the facts, and answer the questions.
SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find
your local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed
under U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). You may send comments regarding this burden estimate or any
other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate or other aspects of this
collection to this address, not the completed form.