TN 13 (03-25)

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:

1. 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.

2. 2. 

   Complete the spouse information including SSN, only if SSI is involved.

3. 3. 

   Complete the type of benefit - Title II Social Security Disability Insurance (Disability) and/or Title XVI Supplemental Security Income (SSI).

4. 4. 

   Complete the name, address, and telephone number of the appointed representative, if applicable.

5. 5. 

   Complete the name, telephone number, and address of the claimant, and the date the form was completed.

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, and the date on the SSA-773-U4, and attach it to the accompanying form(s).