Form HA-501-U5 (01-2015) ef (01-2015)
Use 08-2012 Edition Until Stock is Exhausted
TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS
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)
Form Approved
OMB No. 0960-0269
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:
5. I have additional evidence to submit.
Yes
No
6. Do not complete if the appeal is a Medicare
issue. Otherwise, check one of the blocks
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
the evidence in my case. (Complete
Waiver Form HA-4608)
DATE
RESIDENCE ADDRESS
CITY STATE ZIP CODE
TELEPHONE NUMBER FAX NUMBER
8. NAME OF REPRESENTATIVE (if any)
TELEPHONE NUMBER
FAX NUMBER
TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION- ACKNOWLEDGMENT OF REQUEST FOR HEARING
9. Request received on
(Date)
by:
(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
service organizations provided?
Yes No
12. Interpreter needed
Yes
No
Language (including sign language):
13. Check one:
Initial Entitlement Case
Disability Cessation Case
15. Check all claim types that apply:
Retirement and Survivors Insurance Only (RSI)
Title II Disability - Worker or child only (DIWC)
Title II Disability - Widow(er) only (DIWW)
Title XVI (SSI) Aged only (SSIA)
Title XVI Blind only (SSIB)
Title XVI Disability only (SSID)
Title XVI/Title II Concurrent Aged Claim (SSAC)
Title XVI/Title II Concurrent Blind (SSBC)
Title XVI/Title II Concurrent Disability (SSDC)
Title XVIII Hospital/Supplementary Insurance
(HI/SMI)
Title VIII Only Special Veterans Benefits (SVB)
Title VIII/Title XVI (SVB/SSI)
Other - Specify:
14. HO COPY SENT TO:
HO on
Claims Folder (CF) Attached: Title (T) II; T XVI;
T VIII; T XVIII; T II CF held in FO Electronic Folder
CF requested T II; T XVI; T VIII; T XVIII
16. CF COPY SENT TO: HO on
CF Attached: Title (T) II; T XVI; T XVIII
Other Attached:
Name and source of additional evidence, if not included.
Submit your evidence to the hearing office within 10 days. Your servicing
Social Security office will provide the hearing office's address. Attach an
additional sheet if you need more space.
SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW
See Privacy
Act Notice
7. CLAIMANT SIGNATURE (OPTIONAL)
DATE
ADDRESS
ZIP CODE
CITY
STATE
Other Postentitlement Case
or
(Copy of email or phone report attached)
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.
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.
