You use this form to tell us that you do not want to appear at a hearing before an Administrative Law Judge (ALJ), and that you want the ALJ to decide your case on the evidence in the written record.

Wavier Of Your Right To Personal Appearance Before An Administrative Law Judge

Important

Please read the information below carefully before deciding that you do not want to appear at a hearing.

Under our rules, you have the right to appear at a hearing. At a hearing you may present evidence, have witnesses testify on your behalf, and present your case to the ALJ. Appearing in person at a hearing may help the ALJ make a decision in your case. You may, however, ask the ALJ to decide your case on the evidence in the written record; that is, waive your right to an oral hearing. If you do not want to appear at a hearing, either in person or through a representative, you must tell us this in writing. You use this form to tell us that you do not want to appear at a hearing.

Even if you tell us you do not want to appear at a hearing, the ALJ may schedule a hearing if he or she believes that a personal appearance and testimony by you or someone else may be helpful in deciding your case.

If anyone else is a party to the hearing (someone else whose rights may be unfavorably affected by the ALJ's decision), that person must agree to having the case decided on the written record and must provide us with a written statement to that effect.

If you change your mind and decide you want to appear at a hearing, you must tell us before we mail the ALJ's decision to you. You will find the address and telephone number of the hearing office on the letter we sent to you acknowledging receipt of your request for hearing.

If you have questions about waiving your right to appear at a hearing or how to complete this form, call 1-800-772-1213, your local Social Security office, or the hearing office handling your claim. If you are not certain where your local Social Security office is located, try our Social Security Office Locator Service.

How to complete the form

Claimant: Enter your name or the name of the person on whose behalf the request for hearing was filed.

Wage Earner: If you receive or are applying for Social Security benefits on someone else's work record, enter that person's name.

Social Security Claim Number: The Social Security number (SSN) you enter depends on the type of claim you are appealing. If the appeal is on a claim for:

  • Social Security benefits on your work record, enter your SSN.
  • Social Security benefits on someone else's work record (that is, the wage earner in 2.), enter that person's SSN.
  • Social Security benefits on your work record and on the wage earner's work record, enter both SSNs.
  • Supplemental Security Income (SSI), enter your SSN.
  • Social Security benefits on the wage earner's work record and SSI, enter both SSNs.

Tell us why you do not want to appear at the hearing: In the space provided, tell us why you do not want to appear at a hearing.

Signature: Sign and date the form. If you are waiving the right to appear at a hearing on behalf of a minor child or an incompetent adult, sign your name and your relationship to the claimant (for example, parent for a minor child or legal guardian for an incompetent adult).