Form Ha-501-U5 - Request For Hearing By Administrative Law Judge printable pdf download

Form Approved

SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0269

OFFICE OF HEARINGS AND APPEALS

REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE

See

(Take or mail the signed original to your local Social Security office, the Veterans Affairs

Privacy Act Notice

Regional Office in Manila or any U.S. Foreign Service post and keep a copy for your records)

3. SOC. SEC. CLAIM NUMBER

4. SPOUSE's CLAIM NUMBER

1. CLAIMANT

2. WAGE EARNER, IF DIFFERENT

5. I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination made on my claim because:

An Administrative Law Judge of the Office of Hearings and Appeals will be appointed to conduct the hearing or other proceedings in your case. You will

receive notice of the time and place of a hearing at least 20 days before the date set for a hearing.

6. I have additional evidence to submit.

Yes

7. Check one of the blocks:

I wish to appear at a hearing.

Name and address of source of additional evidence:

I do not wish to appear at a hearing

and I request that a decision be made

based on the evidence in my case.

(Please submit it to the hearing office within 10 days. Your servicing Social Security Office will

(Complete Waiver Form HA-4608)

provide the address. Attach an additional sheet if you need more space.)

You have a right to be represented at the hearing. If you are not represented but would like to be, your Social Security office will give you a list of legal

referral and service organizations. (If you are represented and have not done so previously, complete and submit form SSA-1696 (Appointment of

Representative).)

[You should complete No. 8 and your representative (if any) should complete No. 9. If you are represented and your representative is not available to

complete this form, you should also print his or her name, address, etc. in No. 9.]

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.

(DATE)

8. (CLAIMANT'S SIGNATURE)

9. (REPRESENTATIVE'S SIGNATURE/NAME)

ADDRESS

(ADDRESS)

ATTORNEY;

NON ATTORNEY;

STATE

ZIP CODE

STATE

ZIP CODE

CITY

TELEPHONE NUMBER

FAX NUMBER

TELEPHONE NUMBER

FAX NUMBER

(

)

(

)

(

)

(

)

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION-ACKNOWLEDGMENT OF REQUEST FOR HEARING

10. Request received for the Social Security Administration on

by:

(Date)

(Print Name)

(Title)

(Address)

(Servicing FO Code)

(PC Code)

11. Was the request for hearing received within 65 days of the reconsidered determination?

YES

If no is checked, attach claimant's explanation for delay; and attach copy of appointment notice, letter, or other pertinent material or information in the

Social Security office.

12. Claimant is represented

Yes

15. Check all claim types that apply:

List of legal referral and service organizations provided

(RSI)

RSI only

13. Interpreter needed

Yes

(DIWC)

Title II Disablility-worker or child only

Language (including sign language):