This online service allows you to electronically complete, sign, and submit the Request to Withdraw an Appeals Council Request for Review (Form HA-86). You may use this online service as an alternative to completing a paper version of this form. To complete the form online, you will need a valid email address.

Before beginning the form, you will need to enter and confirm your email address in the online application.

You will receive an email from adobesign@adobesign.com containing a link and instructions on how to access the form. The link will expire after five (5) calendar days. If the link expires, you will need to return to this page to request a new link.

IMPORTANT: We will not process the form until you complete the form, sign the form electronically, and select “Click to Sign” to submit the form. Upon submission, you will be able to download a copy of the signed form within the application. We recommend that you save a copy for your records. You will receive an email confirming your submission.

PLEASE NOTE:

This website is most compatible with Microsoft Edge and Google Chrome.
The form must be electronically completed, signed, and submitted in a single session.
The system will end your session after 60 minutes of inactivity and no information will be saved.
A daily email reminder will be sent for five (5) days or until the form has been submitted.
If you do not receive an email notification within a few minutes of your online submission, be sure to check your email’s junk folder.

Sections 205(a), 1631(d)(1), and 1872 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate determination regarding your request to withdraw your request for review at the Appeals Council.

We will use the information you provide to decide if dismissing your request is appropriate. We may also share your information for the following purposes, called routine uses:

To a congressional office in response to an inquiry from that office made at the request of the subject of a record; and
To a contractor or other Federal agency to assist in the efficient administration of our programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0004, entitled Working File of the Appeals Council, as published in the Federal Register (FR) on April 29, 2009, at 74 FR 19620 and 60-0009, entitled Hearings and Appeals Case Control System, as published in the FR on October 13, 1982, at 47 FR 45589. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.