Form Ssa-561-U2 Social Security Administration - Request For Reconsideration
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SOCIAL SECURITY ADMINISTRATION
TOE 710
OMB No. 0960-0622
REQUEST FOR RECONSIDERATION
(Do not write in this space)
NAME OF CLAIMANT
NAME OF WAGE EARNER OR SELF-EMPLOYED
PERSON (If different from claimant.)
CLAIMANT SSN
CLAIMANT CLAIM NUMBER
SUPPLEMENTAL SECURITY INCOME (SSI) OR
(if different from SSN)
SPECIAL VETERANS BENEFITS (SVB) CLAIM
NUMBER
-
-
-
-
-
-
SPOUSE'S NAME (Complete ONLY in SSI cases)
SPOUSE'S SOCIAL SECURITY NUMBER
(Complete ONLY in SSI cases)
-
-
CLAIM FOR (Specify type, e.g., retirement, disability, hospital /medical, SSI, SVB, etc.)
I do not agree with the determination made on the above claim and request reconsideration. My reasons are:
SUPPLEMENTAL SECURITY INCOME OR SPECIAL VETERANS BENEFITS RECONSIDERATION ONLY
(See the three ways to appeal in the How To Appeal Your Supplemental Security Income (SSI) Or Special Veterans Benefit (SVB) Decision instructions.)
"I want to appeal your decision about my claim for Supplemental Security Income (SSI) or Special Veterans Benefits
(SVB). I've read about the three ways to appeal. I've checked the box below."
Case Review
Informal Conference
Formal Conference
ENTER ADDRESSES FOR THE CLAIMANT AND THE REPRESENTATIVE
CLAIMANT SIGNATURE- OPTIONAL
NAME OF CLAIMANT'S REPRESENTATIVE
NON-ATTORNEY
ATTORNEY
MAILING ADDRESS
MAILING ADDRESS
STATE
ZIP CODE
STATE
ZIP CODE
CITY
CITY
-
-
DATE
DATE
TELEPHONE NUMBER (Include area code)
TELEPHONE NUMBER (Include area code)
(
)
-
(
)
-
TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION
See list of initial determinations
1. HAS INITIAL DETERMINATION
2. CLAIMANT INSISTS
YES
NO
YES
NO
BEEN MADE?
ON FILING
YES
NO
3. IS THIS REQUEST FILED TIMELY?
(If "NO", attach claimant's explanation for delay and attach any pertinent letter, material, or
information in Social Security office.)
SOCIAL SECURITY OFFICE ADDRESS
RETIREMENT AND SURVIVORS RECONSIDERATIONS ONLY (CHECK ONE) REFER TO (GN 03102.125)
NO FURTHER DEVELOPMENT REQUIRED
(GN 03102.300)
REQUIRED DEVELOPMENT ATTACHED
REQUIRED DEVELOPMENT PENDING, WILL FORWARD OR ADVISE STATUS
WITHIN 30 DAYS
DISABILITY DETERMINATION
PROGRAM SERVICE CENTER
DISTRICT OFFICE
ROUTING
SERVICES (ROUTE WITH
RECONSIDERATION
INSTRUCTIONS
OIO, BALTIMORE
DISABILITY FOLDER)
(CHECK ONE)
CENTRAL PROCESSING
ODO, BALTIMORE
OEO, BALTIMORE
SITE (SVB)
NOTE: Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional Office in Manila or any
U.S. Foreign Service post and keep a copy for your records.
Claims Folder
Form SSA-561-U2 (6-2012) ef (06-2012)
Prior Edition May Be Used Until Exhausted
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