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.
- This information collection meets the requirements of
44 U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need
to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. You can find your local Social Security office through SSA's website
at . Offices are also listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to:SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
Form HA-501-U5 (01-2015) ef (01-2015)
PRIVACY ACT STATEMENT
Request for Hearing by Administrative Law Judge
Sections 205(a) (42 U.S.C. 405 (a)), 702 (42 U.S.C. 902), 1631(e) (1) (A), and; (B) (42 U.S.C. 1383(e)
(1) (A) and (B)), 1839(i) (42 U.S.C. 1395r), 1869(b) (1), and (c) (42 U.S.C. 1395ff) of the Social Security
Act, as amended, authorize us to collect this information. We will use the information you provide to
continue processing your claim.
Providing this information is voluntary. However, failing to provide us with all or part of the requested
information may prevent us from making an accurate and timely decision on your claim.
We rarely use the information you supply for any purpose other than for determining problems in Social
Security programs. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in accordance
with approved routine uses, which include, but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records
(e.g., to the Government Accountability Office and the Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigate activities necessary to assure the integrity
of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies.
Information from these matching programs can be used to establish or verify a person's eligibility for
Federally-funded or administered benefit programs and for repayment of payments or delinquent debts
under these programs.
A complete list of routine uses for this information is available in System of Records Notices 60-0089,
Claims Folder System and 60-0050, Completed Determination-Continuing Disablility Determinations.
These notices, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov
or any local Social Security office.
Paperwork Reduction Act Statement
www.socialsecurity.gov