Form Ha-501-U5 - Request For Hearing By Administrative Law Judge - Social Security Administration

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SOCIAL SECURITY ADMINISTRATION
Form Approved
OFFICE OF DISABILITY ADJUDICATION AND REVIEW
OMB No. 0960-0269
REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE
See Privacy
(Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional
Act Notice
Office in Manila or any U.S. Foreign Service post and keep a copy for your records)
1. Claimant Name
2. Claimant SSN
3. Claim Number, if different
4. I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination because:
An Administrative Law Judge of the Social Security Administration's Office of Disability Adjudication and Review or the
Department of Health and Human Services 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. Do not complete if the appeal is a Medicare
5. I have additional evidence to submit.
Yes
No
issue. Otherwise, check one of the blocks
Name and source of additional evidence, if not included.
I wish to appear at a hearing.
I do not wish to appear at a hearing and I
request that a decision be made based on
Submit your evidence to the hearing office within 10 days. Your servicing
the evidence in my case. (Complete
Social Security office will provide the hearing office's address. Attach an
Waiver Form HA-4608)
additional sheet if you need more space.
Representation: You have a right to be represented at the hearing. If you are not represented, your Social Security office
will give you a list of legal referral and service organizations. If you are represented, complete and submit form SSA-1696
(Appointment of Representative) unless you are appealing a Medicare issue.
7. CLAIMANT SIGNATURE (OPTIONAL)
DATE
8. NAME OF REPRESENTATIVE (if any)
DATE
RESIDENCE ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
FAX NUMBER
TELEPHONE NUMBER
FAX NUMBER
TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION- ACKNOWLEDGMENT OF REQUEST FOR HEARING
9. Request received on
by:
(Date)
(Print Name)
(Title)
(Address)
(Servicing FO Code)
(PC Code)
10. Was the request for hearing received within 65 days of the reconsidered determination?
Yes
No
If no, attach claimant's explanation for delay and supporting documents if any.
11. If claimant is not represented, was a list of legal referral
15. Check all claim types that apply:
Yes
No
service organizations provided?
Retirement and Survivors Insurance Only (RSI)
12. Interpreter needed
Yes
No
Title II Disability - Worker or child only
(DIWC)
Language (including sign language):
Title II Disability - Widow(er) only
(DIWW)
13. Check one:
Initial Entitlement Case
Title XVI (SSI) Aged only
(SSIA)
Disability Cessation Case
Other Postentitlement Case
or
Title XVI Blind only
(SSIB)
14. HO COPY SENT TO:
HO on
Title XVI Disability only
(SSID)
Claims Folder (CF) Attached:
Title (T) II;
T XVI;
Title XVI/Title II Concurrent Aged Claim
(SSAC)
T VIII;
T XVIII;
T II CF held in FO
Electronic Folder
Title XVI/Title II Concurrent Blind
(SSBC)
CF requested
T II;
T XVI;
T VIII;
T XVIII
Title XVI/Title II Concurrent Disability
(SSDC)
(Copy of email or phone report attached)
(HI/SMI)
Title XVIII Hospital/Supplementary Insurance
16. CF COPY SENT TO:
HO on
Title VIII Only Special Veterans Benefits
(SVB)
CF Attached:
Title (T) II;
T XVI;
T XVIII
Title VIII/Title XVI
(SVB/SSI)
Other Attached:
Other - Specify:
Form HA-501-U5 (01-2015) ef (01-2015)
TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS
Use 08-2012 Edition Until Stock is Exhausted

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