TN 11 (08-23)
DI 12026.022 Completion of the SSA-773-U4 Waiver of Right to Appear - Disability Hearing
A. Overview of the SSA-773-U4
The SSA-773-U4 allows the individual or an appointed representative to waive the right to appear
at the disability hearing. As described on the form, explain to the individual the
consequences of not appearing.
IMPORTANT: The individual must understand that filing the waiver does not waive the disability
hearing process, only the right to a personal appearance at the hearing. If the individual
waives their right to appear at the hearing, the disability hearing officer (DHO)
will base the reconsidered determination solely on the evidence in the case folder.
The individual can reverse the waiver anytime prior to the DHO's written reconsidered
determination.
B. Completion of the SSA-773-U4
Complete the SSA-773-U4 as follows:
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1.
Complete the name and Social Security Number (SSN) of the claimant following the same
format used to complete the SSA-789 (Request for Reconsideration-Disability Cessation Right to Appear). For additional
information on completing the SSA-789, see DI 12026.021 Completion of the SSA-789 Request for Reconsideration - Disability Cessation Right
to Appear.
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2.
Complete the type of benefit - Title II Social Security Disability Insurance (Disability)
and/or Title XVI Supplemental Security Income (SSI).
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3.
Complete the spouse information including SSN, only if SSI is involved.
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4.
Ask the individual or their representative to sign the form, complete the address,
telephone, and date boxes.
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5.
Have the witnesses sign the form and complete the appropriate address information,
if applicable.
NOTE: If the SSA-773-U4 is completed at the same time as either the SSA-789 or the SSA-770-U4,
Notice Regarding Substitution of Party upon Death of Claimant - Reconsideration of
Disability Cessation, complete only the name of claimant, the SSN, the signature,
and the date on the SSA-773-U4, and attach it to the accompanying form(s).