Ssa 789 2012 form-2026

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The document is a 'Request for Reconsideration' form from the Social Security Administration, used by claimants who disagree with the decision to stop their disability benefits. It outlines the process for requesting a reconsideration, including options for appearing at a hearing, submitting additional information, and the legal implications of providing false information. The form also includes privacy notices regarding the use of personal data.

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Click ‘Get Form’ to open the SSA 789 2012 form in the editor.
Begin by entering the claimant's name and Social Security number in the designated fields. If applicable, include the name and Social Security number of the wage earner or self-employed person.
Indicate the type of benefit you are requesting reconsideration for by checking the appropriate box (e.g., Disability Worker, SSI, Widow, etc.).
In the section provided, clearly state your reasons for disagreeing with the determination to stop disability benefits. Be specific and include any additional information if necessary.
Choose whether you wish to appear at a face-to-face hearing or not by checking Block 1 or Block 2. If you need an interpreter, specify the language required.
Sign and date the form at the bottom. Ensure that either you or your representative signs it. If signed by mark (X), two witnesses must also sign.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (53 Votes)
2015	4.3 Satisfied (164 Votes)
2012	4.4 Satisfied (108 Votes)
2009	4 Satisfied (31 Votes)
2003	4 Satisfied (25 Votes)

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