Get Ha 501 U5

CF COPY SENT TO Title VIII Only Special Veterans Benefits CF Attached Other Attached Form HA-501-U5 01-2015 ef 01-2015 Use 08-2012 Edition Until Stock is Exhausted Other - Specify RSI DIWC DIWW SSIA SSIB SSID SSAC SSBC SSDC HI/SMI SVB SVB/SSI TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS PRIVACY ACT STATEMENT Request for Hearing by Administrative Law Judge Sections 205 a 42 U.S.C. Form Approved OMB No. 0960-0269 SOCIAL SECURITY ADMINISTRATION OFFICE OF DISABILITY ADJUDICATION AND REVIEW REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE Take or mail the completed 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 2. Claimant SSN 3. Claim Number if different 1. Claimant Name See Privacy Act Notice 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. Claimant SSN 3. Claim Number if different 1. Claimant Name See Privacy Act Notice 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. Attach an additional sheet if you need more space. I do not wish to appear at a hearing and I request that a decision be made based on the evidence in my case. Complete Waiver Form HA-4608 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. Complete Waiver Form HA-4608 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. 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 RESIDENCE ADDRESS ADDRESS CITY STATE TELEPHONE NUMBER FAX NUMBER ZIP CODE TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION- ACKNOWLEDGMENT OF REQUEST FOR HEARING 9. You will receive notice of the time and place of a hearing at least 20 days before the date set for a hearing. 5. I have additional evidence to submit. 6. Do not complete if the appeal is a Medicare issue. Otherwise check one of the blocks No Yes Name and source of additional evidence if not included* I wish to appear at a hearing.