Form Ssa-561-U2 - Request For Reconsideration Form
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1Form Approved
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
(If different from claimant.)
PERSON
SOCIAL SECURITY CLAIM NUMBER
SUPPLEMENTAL SECURITY INCOME (SSI) OR SPECIAL
VETERANS BENEFITS (SVB) CLAIM NUMBER
(Complete ONLY in SSI cases)
SPOUSE'S NAME
SPOUSE'S SOCIAL SECURITY NUMBER
(Complete ONLY in SSI cases)
(Specify type, e.g., retirement, disability, hospital insurance, SSI, SVB, etc.)
CLAIM FOR
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
Formal Conference
Informal 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
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
DATE
TELEPHONE NUMBER
DATE
(Include area code)
(Include area code)
TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION
See list of initial determinations
1. HAS INITIAL DETERMINATION
2. CLAIMANT INSISTS
NO
YES
NO
YES
BEEN MADE?
ON FILING
3. IS THIS REQUEST FILED TIMELY?
YES
NO
(If "NO", attach claimant's explanation for delay and attach only pertinent letter, material, or
information in social security office.)
SOCIAL SECURITY OFFICE
RETIREMENT AND SURVIVORS RECONSIDERATIONS ONLY (CHECK ONE) REFER TO (GN 03102.125)
ADDRESS
NO FURTHER DEVELOPMENT REQUIRED
(
GN 03102.300)
REQUIRED DEVELOPMENT ATTACHED
REQUIRED DEVELOPMENT PENDING, WILL FORWARD OR ADVISE STATUS
WITHIN 30 DAYS
PROGRAM SERVICE CENTER
DISABILITY DETERMINATION
DISTRICT OFFICE
ROUTING
SERVICES (ROUTE WITH
RECONSIDERATION
INSTRUCTIONS
OIO, BALTIMORE
DISABILITY FOLDER)
(CHECK ONE)
CENTRAL PROCESSING
OEO, BALTIMORE
ODO, 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 (7-2003) EF (3-2006) Destroy Prior Editions
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