Request For Reconsideration Disability Cessation Right To Appear Ssa789
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1
2Form SSA-789 (04-2016) UF
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Page 1 of 2
Social Security Administration
OMB No. 0960-0349
FOR SOCIAL SECURITY
REQUEST FOR RECONSIDERATION - DISABILITY CESSATION RIGHT TO APPEAR
OFFICE USE ONLY
(SEE REVERSE SIDE FOR PAPERWORK/PRIVACY ACT NOTICE)
(DO NOT WRITE IN
NAME OF CLAIMANT
SOCIAL SECURITY NUMBER
THIS SPACE)
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER
FO Code
(If different from Claimant)
Benefit Continuation
SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPLETE ONLY IN
Foreign
SUPPLEMENTAL SECURITY INCOME CASE)
Language Notice
DISABILITY
SSI
TYPE OF
WORKER
WIDOW
CHILD
DISABILITY
BLIND
CHILD
BENEFIT
I DO NOT AGREE WITH THE DETERMINATION TO STOP DISABILITY BENEFITS
AND I REQUEST RECONSIDERATION.
My reasons are (reasons should relate to the basis for stopping disability benefits and be as specific as possible):
NOTE: If the notice of the determination on your claim is dated more than 65 days ago, include your reason for not making this
request earlier. Include the date on which you received the notice.
I AM SUBMITTING THE FOLLOWING ADDITIONAL INFORMATION (If "NONE" write "NONE")
(Attach additional page if needed):
CHECK BLOCK 1 AND THE STATEMENTS THAT APPLY OR CHECK BLOCK 2.
1. I (and/or my representative) wish to appear at a face-to-face disability hearing. The disability hearing will be with a
person called a disability hearing officer and it will let me explain why I do not agree with the decision to stop benefits.
I need an interpreter at the disability hearing - Language
(If you need an interpreter, SSA will provide one at no cost to you.)
OR
2. I do not wish to appear nor do I wish a representative to appear for me at the disability hearing. I have been advised of
my right to have a disability hearing. I understand that a disability hearing will give me a chance to present witnesses. It
will also let me explain to the disability hearing officer why my disability benefits should not end. I understand that this
chance to be seen and heard could help the disability hearing officer learn about the facts in my case. The disability
hearing officer would give me a chance to have people who know about my condition give information and explain how my
condition keeps me from working and restricts my activities. I have been told about my right to representation at the
disability hearing, including representation by an attorney or other person of my choice. Although the above has been
explained to me, I do not want to appear at a disability hearing, or have someone represent me at a disability hearing. I
prefer to have the disability hearing officer decide my case on the evidence in my file, plus any evidence that I submit or
that may be obtained by the Social Security Administration. I have been advised that if I change my mind, I can request a
disability hearing prior to the writing of a decision in my case. In this case, I can make the request with any Social
Security office.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.
EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH
CLAIMANT SIGNATURE
SIGNATURE OR NAME OF CLAIMANT'S REPRESENTATIVE
STREET ADDRESS.
REPRESENTATIVE'S ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
DATE
TELEPHONE NUMBER
DATE
Witnesses are required ONLY if this form has been signed by mark (X). If signed by mark (X), two witnesses to the
signing who know the person requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
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