Last Update: 9/2/2005 (Transmittal I-2-64)
HA 01260.099 Sample - Waiver
by Claimant of Right to Inspect Additional Evidence Under the Provisions
of Privacy Act of 1974
Renumbered from HALLEX section I-2-6-99
WAIVER BY CLAIMANT
TO PROVISIONS OF PRIVACY ACT OF
1974 PERTAINING TO EVIDENCE
RECEIVED SUBSEQUENT TO HEARING
I hereby waive my right to inspect, prior to decision, any
additional information received by the Administrative Law Judge
in connection with my application for benefits under the Social
Security Act, as amended, and request that the information obtained
be made a part of the record in my case and considered by the Administrative
Law Judge in determining his decision in this matter.
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___________________________________
Claimant/Wage-Earner/Guardian
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___________________________________
Date
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___________________________________
Social
Security Number
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