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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 404.971 and 416.1471
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
HA-85
Request to Withdraw a Hearing Request
HA-85 - Current Version.pdf
No
Paper Only
Form
HA-86
Request to Withdraw an Appeals Council Request for Review
HA-86 -Current Version.pdf
No
Paper Only
Form and Instruction
e85 (submittable PDF)
Request to Withdraw a Hearing Request
e85 Screen Package.pdf
www.ssa.gov
Yes
Yes
Fillable Fileable Signable
Form and Instruction
HA-86 (Submittable PDF)
Withdraw an Appeals Council Request for Review
HA-86 Submittable PDF Screen Package.pdf
www.ssa.gov
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
1,606
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,606
0
0
0
0
1,606
Annual IC Time Burden (Hours)
268
0
0
0
0
268
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.