I-2-6-97.Exhibit – Acknowledgement of Postponement In Order to Obtain Representation

Last Update: 5/1/17 (Transmittal I-2-199)

Acknowledgment of Postponement In Order To Obtain Representation

IN THE MATTER OF

________________________________

Claimant

________________________________

Social Security Number

I have requested a postponement of my hearing so that I may obtain a representative to help me in my claim for benefits. I understand that I am entitled to have only one postponement in order to obtain a representative (either an attorney or other qualified representative) and that any subsequent hearing will be rescheduled at least 75 days from the notice of subsequent hearing, unless I waive the right to the 75-day notice requirement.

I have been advised, both orally and in writing, that if I do not have a representative by the next scheduled hearing, I must be prepared to proceed with the hearing without a representative and, absent extraordinary circumstances, no further postponement will be granted in order for me to get a representative.

________________________________

Signature of Claimant

________________________________

Date

________________________________

Witness Exhibit no.