10. Check one:
4. I request that the Appeals Council review the Administrative Law Judge's action on the above claim because:
THE SOCIAL SECURITY ADMINISTRATION STAFF WILL COMPLETE THIS PART
Form HA-520-U5 (01-2016) UF (01-2016)
Destroy Prior Editions
SOCIAL SECURITY ADMINISTRATION
REQUEST FOR REVIEW OF HEARING DECISION/ORDER
Form Approved
OMB No. 0960-0277
(Do not use this form for objecting to a recommended ALJ decision.)
(Either mail the signed original form to the Appeals Council at the address shown below, or take or mail
the signed original to your local Social Security office, the Department of Veterans Affairs Regional Office
in Manila, or any U.S. Foreign Service Post and keep a copy for your records.)
See
Privacy Act
Notice
7. Request received for the Social Security Administration on
(Date)
by:
(Print Name)
(Title) (Address) (Servicing FO Code)
8. Is the request for review received within 65 days of the ALJ's Decision/Dismissal?
Yes No
(1) attach claimant's explanation for delay; and
(2) attach copy of appointment notice, letter or other pertinent material or information in the
Social Security Office.
Initial Entitlement
Termination or other
11. Check all claim types that apply:
SSI Blind
(SSIB)
SSI Disability
(SSID)
Title VIII Only
(SVB)
Title VIII/Title XVI
(SVB/SSI)
Other - Specify:
1. CLAIMANT NAME 2. CLAIMANT SSN
3. CLAIM NUMBER (If different than SSN)
5. CLAIMANT'S SIGNATURE DATE
PRINT NAME
ADDRESS CITY, STATE, ZIP
TELEPHONE NUMBER FAX NUMBER
6. REPRESENTATIVE'S SIGNATURE
DATE
PRINT NAME
ATTORNEY
NON-ATTORNEY
ADDRESS CITY, STATE, ZIP
TELEPHONE NUMBER FAX NUMBER
(SSIA)SSI Aged
(DIWC)
Disability-Child
(DIWW)
Disability-Widow(er)
(DIWC)
Disability-Worker
(RSI)
Retirement or survivors
TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY
FOR YOUR RECORDS
(PC Code)
If you have additional evidence that relates to the period on or before the date of the hearing decision, you must inform the
Appeals Council about it or submit it. If you have a representative, then your representative must help you obtain the
evidence unless the evidence falls under an exception. You may also submit any other additional evidence to the Appeals
Council. If you need additional time to submit evidence or legal argument, you must request an extension of time in writing
now. This will ensure that the Appeals Council has the opportunity to consider the additional evidence before taking its
action. If you submit neither evidence nor legal argument now or within any extension of time the Appeals Council grants,
the Appeals Council will take its action based on the evidence currently in your file.
ADDITIONAL EVIDENCE
IMPORTANT: WRITE YOUR SOCIAL SECURITY NUMBER ON ANY LETTER OR MATERIAL YOU SEND US. IF YOU
RECEIVED A BARCODE FROM US, THE BARCODE SHOULD ACCOMPANY THIS DOCUMENT AND ANY OTHER
MATERIAL YOU SUBMIT TO US.
SIGNATURE BLOCKS: You should complete No. 5 and your representative (if any) should complete No. 6. 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. 6.
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.
APPEALS COUNCIL
OFFICE OF DISABILITY ADJUDICATION
AND REVIEW, SSA
5107 Leesburg Pike
FALLS CHURCH, VA 22041 - 3255
9. If "No"
checked:
Please grant me an extension of time to submit evidence or argument.
