Information Collection

Request for Change in Time/Place of Disability Hearing

IC 9228 under ICR 201301-0960-003 · OMB 0960-0348.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0348 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-769-U4 Request for Change in Time/Place of Disability Hearing Form
SSA-769-U4 Request for Change in Time/Place of Disability Hearing SSA-769-U4 (revised).pdf Form
SSA-769-U4 (current).pdf SSA-769-U4 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Change in Time/Place of Disability Hearing	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.1414(c)(2) 20 CFR 404.914(c)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-769-U4	Request for Change in Time/Place of Disability Hearing	SSA-769-U4 (revised).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,483	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7,483	7,483
Annual IC Time Burden (Hours)	998	998
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-769-U4	SSA-769-U4 (current).pdf	02/15/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.