Old HA-501

Form Approved
OMB No. 0960-0269

SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW

REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE

See
Privacy Act Notice

(Take or mail the signed 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)
1. CLAIMANT

3. SOC. SEC. CLAIM NUMBER

2. WAGE EARNER, IF DIFFERENT

-

4. SPOUSE's CLAIM NUMBER

-

-

-

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

An Administrative Law Judge of the Office of Disability Adjudication and Review 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.

Yes

6. I have additional evidence to submit.

No

7. Check one of the blocks:

I wish to appear at a hearing.

Name and address of source of additional evidence:

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)

(Please submit it to the hearing office within 10 days. Your servicing Social Security Office will
provide the address. Attach an additional sheet if you need more space.)

You have a right to be represented at the hearing. If you are not represented but would like to be, your Social Security office will give you a list of legal
referral and service organizations. (If you are represented and have not done so previously, complete and submit form SSA-1696 (Appointment of
Representative).)
[You should complete No. 8 and your representative (if any) should complete No. 9. 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. 9.]
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.
(DATE)
(DATE)
8. (CLAIMANT'S SIGNATURE)
9. (REPRESENTATIVE'S SIGNATURE/NAME)
ADDRESS

(ADDRESS)

STATE

CITY

ZIP CODE

ATTORNEY;

NON ATTORNEY;
STATE

CITY

ZIP CODE

TELEPHONE NUMBER

FAX NUMBER

(

(

)

-

)

-

-

TELEPHONE NUMBER

FAX NUMBER

(

(

)

-

)

-

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION-ACKNOWLEDGMENT OF REQUEST FOR HEARING
10. Request received for the Social Security Administration on

by:
(Date)

(Title)

(Print Name)

(Address)

(Servicing FO Code)

(PC Code)

11. Was the request for hearing received within 65 days of the reconsidered determination?
YES
NO
If no is checked, attach claimant's explanation for delay; and attach copy of appointment notice, letter, or other pertinent material or information in the
Social Security office.
Yes
12. Claimant is represented
15. Check all claim types that apply:
No
List of legal referral and service organizations provided
13. Interpreter needed

Yes
Language (including sign language):

14. Check one:

No

Initial Entitlement Case
Disability Cessation Case
Other Postentitlement Case
HO on

16. HO COPY SENT TO:

CF Attached:
Title II;
Title XVI;
Title II CF held in FO to establish CAPS ORBIT; or
CF requested
Title II;
Title XVI
(Copy of teletype or phone report attached)

HO on

17. CF COPY SENT TO:

CF Attached:
Other Attached:

Title II;

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

Title XVI

Title VIII; or
Title VIII

RSI only

(RSI)

Title II Disablility-worker or child only

(DIWC)

Title II Disability-Widow(er) only

(DIWW)

SSI Aged only

(SSIA)

SSI Blind only

(SSIB)

SSI Disability only

(SSID)

SSI Aged/Title II

(SSAC)

SSI Blind/Title II

(SSBC)

SSI Disability/Title II

(SSDC)

HI Entitlement

(HIE)

Title VIII Only

(SVB)

Title VIII/Title XVI

(SVB/SSI)

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

PAPERWORK/PRIVACY ACT NOTICE
The Social Security Act (sections 205(a), 702, 1631(e)(1)(a) and (b), and 1869(b)
(1) and (c), and Public Law 106-169 (Section 809(a)(1) 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 when 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 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. 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 (8-2006) ef (8-2006)