Get SSA HA-501-U5 2003
EQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE See Privacy Act Notice (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) 1. CLAIMANT 3. SOC. SEC. CLAIM NUMBER 2. WAGE EARNER, IF DIFFERENT - 4. SPOUSE's CLAIM NUMBER - - - 5. I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination made on my claim because: An Administrat.
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