Form Ssa-561-U2 2007 - Request For Reconsideration - Social Security
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SOCIAL SECURITY ADMINISTRATION
TOE 710
OMB No. 0960-0622
(Do not write in this space)
REQUEST FOR RECONSIDERATION
NAME OF CLAIMANT
NAME OF WAGE EARNER OR SELF-EMPLOYED
PERSON (If different from claimant.)
CLAIMANT CLAIM NUMBER
CLAIMANT SSN
SUPPLEMENTAL SECURITY INCOME (SSI) OR
(if different from SSN)
SPECIAL VETERANS BENEFITS (SVB) CLAIM
NUMBER
-
-
-
-
-
-
SPOUSE'S SOCIAL SECURITY NUMBER
SPOUSE'S NAME (Complete ONLY in SSI cases)
(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
EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH
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.
CLAIMANT SIGNATURE
SIGNATURE OR 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)
CENTRAL PROCESSING
(CHECK ONE)
ODO, BALTIMORE
OEO, BALTIMORE
SITE (SVB)
NOTE: Take or mail the signed 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 (9-2007) ef (9-2007)
Prior Edition May Be Used Until Exhausted
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