I-2-6-98.Sample - Waiver of Representation by the Claimant

Last Update: 9/2/05 (Transmittal I-2-64)

WAIVER OF REPRESENTATION BY THE CLAIMANT

Received Prior to the Hearing

I understand my right to representation at the hearing. I voluntarily waive this right, and I request to proceed without a representative. I also acknowledge that I received a list of organizations that provide legal services prior to receiving the Notice of Hearing.

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Claimant/Wage-Earner/Guardian

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Date

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Social Security Number