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 W....
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the SSA-789-U4 online
The SSA-789-U4 form, also known as the request for reconsideration for disability cessation, is an essential document for individuals seeking to contest the termination of their disability benefits. This guide will provide clear, step-by-step instructions on how to accurately complete the form online.
Follow the steps to successfully complete the SSA-789-U4 online.
- Click the ‘Get Form’ button to obtain the form and open it in your editing interface.
- Fill in the claimant’s name and social security number in the designated fields at the top of the form. Ensure that this information is accurate as it is crucial for identifying your case.
- If applicable, enter the name and social security number of the wage earner or self-employed person in the next provided fields, ensuring this information is also correct.
- Complete the section for the spouse's name and social security number only if you are applying under Supplemental Security Income (SSI).
- Indicate the type of benefit you are requesting reconsideration for by selecting one of the options available: disability, widow, SSI, child, etc.
- In the space provided, clearly state that you do not agree with the determination to stop your disability benefits and outline your reasons for this request. Be specific and relate your reasons directly to the decision that was made.
- If your notice was dated more than 65 days ago, include your reason for the delay in filing this request along with the date you received the notice.
- List any additional information you are submitting with this form. If you have none, write 'NONE' in the space provided.
- Choose between Block 1 or Block 2 regarding whether you wish to appear at a disability hearing. If selecting Block 1, specify if you need an interpreter and the language required. If selecting Block 2, acknowledge your understanding of foregoing the hearing.
- Sign and date the form. Ensure that either the claimant or the representative, if applicable, signs the form. Enter the necessary address and contact details.
- If the form is signed by mark (X), make sure two witnesses provide their signatures and addresses in the section provided.
- Review the completed form for accuracy before submission. Once verified, save your changes, and consider downloading or printing a copy for your records and sharing as necessary.
Take the next step in your process by completing the SSA-789-U4 online.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
SSI. DISABILITY. BLIND. CHILD. I DO NOT AGREE WITH THE DETERMINATION TO STOP DISABILITY...
Form SSA-789-U4 (04-2012) EF (04-2012). SOCIAL SECURITY ADMINISTRATION. REQUEST FOR...
Get answers to your most pressing questions about US Legal Forms API.
What is an SSA form?
A Social Security 1099 or 1042S Benefit Statement, also called an SSA-1099 or SSA-1042S, is a tax form that shows the total amount of benefits you received from Social Security in the previous year.
What is a SSA 7005 form?
The Social Security Statement (Form SSA-7005-SM-OR or SSA-7005-SM-SI) is the form used to provide people who have worked under the Social Security program with information regarding their reported earnings, estimates of the tax contributions they and their employers have paid, and the potential benefits that they and ...
What Is Social Security Administration authorization?
SSA and its affiliated State disability determination services use Form SSA-827, "Authorization to Disclose Information to the Social Security Administration (SSA)" to obtain medical and other information needed to determine whether or not a claimant is disabled.
What is Form SSA 787?
The SSA-787, Medical Source Opinion of Patient's Capability to Manage Benefits, is the preferred vehicle for obtaining medical evidence of capability.
How do I fill out an SS 5 form?
0:32 2:00 Suggested clip Form SS 5 - YouTubeYouTubeStart of suggested clipEnd of suggested clip Form SS 5 - YouTube
What is the SSA 3288 form used for?
Social Security Form SSA-3288 is a form that you can sign to give your consent to the SSA to release information about you to a third party. The information you want to release includes, but isn't limited to: Your Social Security Number (you could also accomplish this with Form SSA-89)
What is Form SSA 623?
The representative payee is required to provide the Social Security Administration (SSA) with detailed information on a regular basic about how benefits are spent. This is the purpose of the form SSA-623. Why This Form is Important. A payee acts as an advocate and accountant for a disabled individual.
What is Form SSA 1724 f4 used for?
Who needs a Form SSA-1724-F4? This form is used by the relatives of the deceased social security recipient or the legal representative of the estate. Among the immediate relatives allowed to receive these payments are the spouse, children, and parents of the deceased.
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.