Form HA-501 Request for Hearing by Administrative Law Judge

SOCIAL SECURITY ADMlNiSTRATlON
QFFICE OF DlSABILITYA&AQKATlON AND REVIEW

Form Approved
OM8 No. 09604269

REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE

See
Privacy Act Notice

(Jake or mail the signed original to your local Social Security oflce, the Veterans Affairs
Regional Ofiice in Manila or any U.S. Foreiun Service post and keep a copy fw your records)
3. SOC SEC. CLAIM NUMBER
1. CLAIMANT
2. WAGE EARNER. IF DIFFERENT

-

4

SWUSE'ECLAIM NUMBER

-

-

-

5.1 REQUEST A HEARING BEFORE AN ADMlNiSTRATiVE LAW JUDGE. I disagree with the determination made on my claim because:

An Administrabve Law Judge of h e Office of Disability Adjudication and Review will be appointed to conduct the hearing or other proceedings in your case.
You will receive notice of ~e time and place of a hearing at least 20 days before the date set for a hearing.

6. i have additional evidence to submit.

[7 No

Yes

7. Check one of @ blocks:

i wish to appear at a hearing.

Name and address of source of additional evidence:

q i do not wish to appear at a heating

I

r
clng Soosl Searlty Officew
(Please s~omllit to me heanng oRce nnh n 19 oays Y o ~ sew
provide the aaoress Attacn an aaa uonal sneel f YOL need more space J

and I reauest that a decision be made
oased on me ev dance n my case
(Complete W a ~ v Fonr
~ r nA-4608)

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I

YOLnave a r gnt to be representeo at :he hear ng if yod are no1 ropresonteo b ~WOLOO
t
*e iu be, yodr Soc~alSecdnty offce MI, g ve yod a llsl of ~ega,
referral an0 sewace organlzatons. (If bod are representeo and have not done so prev o ~ s ~complete
y.
ana rorntt form SSA-1696 ,&po
ntment of
.
Representative).)
~ ( O Ushould complete No. 8 and your representative (if any) should complete No. 9. If you are represented and your representative is not available to
complete h i s form, you should also print hisor her name, address, etc. in No. 9.1
i declare under penalty of per ury tnat Ihave examined all the information on this form, and on any accompanying statements or forms, and it is
true and correct to the best o my knowledge.
8. (CLAIMANT'S SIGNATURE)
(DATE)
9. (REPRESENTATIVE'S SIGNATUREMAME)
(DATE)
~

I

I

(ADDRESS)

ADDRESS
CITY

STATE

ZIP CODE

CITY

-

FAX NUMBER

TELEPHONE NUMBER
(
)

(

(

NON AlTORNEY:
STATE

TELEPHONE NUMBER

-

)

q AnORNEY;

)

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ZIP CODE

-

FAX NUMBER

(

)

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TO BE COMPLETED BY SOCIAL S E C U R I N ADMINISTRATION-ACKNOWLEDGMENT OF REQUEST FOR HEARING
10. Request receivedtor the S o 4 Security Adminisbation on
bv:
(Dab)
(Print Name)

1C Was h e reguest for heaiinn received within 65 days of h e remnsidered determindon?
DYES
O N 0
If no is h d e d , a M daimanrs expianatkm for d&y: and attach copy of appolnbnent notice, letter, or o h pertinent material or information In the
Soaal Securitv office.
12. Claimant is represented
Yes
NO
115. c m n k a i ~
daim types mat apply:
List of legal refenal and s e ~ c organlzations
e
pronded
1
(RSf)
[7 RSI only
13 Intsmrelpr needed
q "es
No
(DiWC)
[7 Title Ii Disablility-worker or child oniy
Language (Induding sign language):
(DlwW)
[7 Title II Disability-Widow(8r) only
14. Check one:
Infmi Enmement Case
(SSlA)
[7 SSI Aged oniy
DissbiliN Cessation Case
(SSlB)
SSI Blind only

0

-

n

HO on

16. HO COPY SENT TO:

=Attached:
Tieii;
TMeXVI:
W e iI CF held m FO to establish CAPS ORBIT, or
CF requested
Ttk 11;
TtleXVl
(Copy of teletype or phone report attached)
HO on
17. CF COPY SENT TO:

q

CF Attached:
Other Attached:

Title II:

Form HA-501-U5 (8-2006) ef (8-2006)
Destroy Prior Editions

Title XVI

SSl Disability only
TitleVIiI; or

q Tltle Vlll

(SSID)

Ij SSl AgedTTie Ii

(SSAC)

SSI BlincliTitle II

(SSBC)

IjSSI Disabilityrtle II

(SSW

1
3 HI Entitlement
Title Vlll Only
Title VlllKitle XVI

[7 Other - Specify:
TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS

PAPERWORKIPRIVACY ACT NOTICE
The Social Security Act (sections 205(a), 702, 1631(e)(l)(a) and (b), and 1869(b)
(I) and (c), and Public Law 106-169 (Section 809(a)(l) of Sections 251(a)) as
appropriate) authorizes the collection of information on this form. We need the
information to continue processing your claim. You do not have to give it, but if
you do not you may not receive benefits under the Social Security Act. We may
give out the information on this form without your written consent if we need to
get more information to decide if you are eligible for benefits or if a Federal law
requires us to do so. Specifically, we may provide information to another
Federal, State, or local government agency which is deciding your eligibility for
a government benefit or program; to the President or a Congressman inquiring on
your behalf; to an independent party who needs statistical information for a
research paper or audit report on a Social Security program; or to the Department
of Justice to represent the Federal Government in a court suit related to a
program administered by the Social Security Administration. We explain, in the
Federal Register, these and other reasons why we may use or give out
information about you. If you would like more information, get in touch with
any Social Security office, the Veterans Affairs Regional Office in Manila, or
any U.S. Foreign Service post.
We may also use the information you give us whcn we match records by
computer. Matching programs compare our records with those of other Federal,
State, or local government agencies. Many agencies may use matching programs
to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information about you may be
used or given out are available in Social Security offices. If you want to learn
more about this, contact any Social Security office, the Veterans Affairs
Regional Office in Manila, or any U.S. Foreign Service post.
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. $ 3507, as amended by Section 2 of the Papemork
Reduction.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. Yotr may send comments on our time estimate above to:
SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send @ comments
relating to our time estimate to this address, not the completedjorm

Form HA-501-U5 (8-2006)ef (8-2006)