Get SSA-789-U4 2019-2024

1. SIGNATURE OF WITNESS ADDRESS NUMBER AND STREET CITY STATE ZIP CODE ADDRESS NUMBER AND STREET CITY STATE ZIP CODE Form SSA-789-U4 09-2015 EF 09-2015 Use Prior edition until exhausted 12-2009 EF 12-2009 CLAIMS FILE PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE Sections 205 a b 1631 c 1 A and B of the Social Security Act as amended allow us to collect this information. We will use the information you provide to determine your eligibility for disability benefits. SOCIAL SECURITY ADMINISTRATION REQUEST FOR RECONSIDERATION - DISABILITY CESSATION RIGHT TO APPEAR SEE REVERSE SIDE FOR PAPERWORK/PRIVACY ACT NOTICE NAME OF CLAIMANT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON If different from Claimant FORM APPROVED OMB No* 0960-0349 FOR SOCIAL SECURITY OFFICE USE ONLY DO NOT WRITE IN THIS SPACE FO Code Benefit Continuation SPOUSE S NAME AND SOCIAL SECURITY NUMBER COMPLETE ONLY IN SUPPLEMENTAL SECURITY INCOME CASE Foreign Language Notice DISABILITY SSI CHILD WORKER BLIND WIDOW I DO NOT AGREE WITH THE DETERMINATION TO STOP DISABILITY BENEFITS AND I REQUEST RECONSIDERATION* My reasons are reasons should relate to the basis for stopping disability benefits and be as specific as possible NOTE If the notice of the determination on your claim is dated more than 65 days ago include your reason for not making this request earlier. Include the date on which you received the notice. TYPE OF BENEFIT I AM SUBMITTING THE FOLLOWING ADDITIONAL INFORMATION If NONE write NONE Attach additional page if needed CHECK BLOCK 1 AND THE STATEMENTS THAT APPLY OR CHECK BLOCK 2. 1. I and/or my representative wish to appear at a face-to-face disability hearing. The disability hearing will be with a person called a disability hearing officer and it will let me explain why I do not agree with the decision to stop benefits. I need an interpreter at the disability hearing - Language If you need an interpreter SSA will provide one at no cost to you. OR 2. I do not wish to appear nor do I wish a representative to appear for me at the disability hearing. I have been advised of my right to have a disability hearing. I understand that a disability hearing will give me a chance to present witnesses. It will also let me explain to the disability hearing officer why my disability benefits should not end. I understand that this chance to be seen and heard could help the disability hearing officer learn about the facts in my case. The disability hearing officer would give me a chance to have people who know about my condition give information and explain how my condition keeps me from working and restricts my activities. I have been told about my right to representation at the disability hearing including representation 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 in my file plus any evidence that I submit or that may be obtained by the Social Security Administration* I have been advised that if I change my mind I can request a I declare under penalty of perjury that I have examined all the information on this form and on any accompanying statements or forms and it is true and correct to the best of my knowledge.