Form HA-1 Appeal Under the Railroad Retirement or Railroad Unemplo

UNITED STATES OFAMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
O.M.B. NO. 3220-0007

SOCIAL SECURITY NUMBER

PRINT NAME (First, Middle Initial, Last)

APPEAL UNDER THE
RAILROAD RETIREMENT ACT
OR
THE
UNEMPLoYMENT INSLIRANCE ACT
IMPORTANT: PLEASE READ FORM HA-2
BEFORE COMPLETING THlS FORM

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RRB CLAIM NUMBER
(R.R.A. Appeals Only)
TELEPHONE NO.
AREA CODE

PRINT ADDRESS (Number, StreeVApt. No.. P.O. Box)

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'ITY

STATE

ZIP CODE

Before completing this form read the information contained on the back of this form.

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COMPLETE EITHER ITEM A OR B BELOW:

A.
B.

a
a

Ihereby appeal the reconsideration decision reported in a letter dated
Ihereby appeal the hearings officer's decision reported in a letter dated

This appeal is based on what I believe to be mistakes of fact or errors of law. Details of these mistakes are as follows:

(ATTACH ADDITIONAL SHEETS IF NECESSARY)

I INTEND TO SUBMIT ADDITIONAL EVIDENCE AS FOLLOWS: (if none, so state)

THIS FORM SHOULD BE SENT TO THE BUREAU OF HEARINGS AND APPEALS, RAftROAD RETIREMENT BOARD, 844 NORTH RUSH
STREET, CHICAGO, ILLINOIS 60611-2092, OR TO ANY OFFICE OF THE RAILROAD RETIREMENT BOARD. SEE FORM HA-2 FOR
INFORMATION ON TIME LIMITATIONS.

IF CLAIMANT IS REPRESENTED:

SIGNATURE OF
CLAIMANT

Name of
Representative

DATE SIGNED

Address

IF THlS APPEAL I S FILED B Y A PERSON OTHER THAN
CLAIMANT, STATE RELATIONSHIP T O T H E CLAIMANT
BELOW:

Phone No. (

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a Attorney

a

FORM HA-1 (10-98) DESTROY PREVIOUS EDITIONS

Non-Attorney

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(EXECUTOR, ADMINISTRATOR, GUARDIAN, ETC.)

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COLLECTION AND USE OF INFORMATION FROM
YOUR APPEAL FORM-PRIVACY ACT NOTICE
Under section 7 (b)(6) of the Railroad Retirement Act of 1974 and section 5(b) of the
Railroad Unemployment lnsurance Act, the Railroad Retirement Board (RRB) is
authorized to ask you for the information on the reverse side of this form. You are not
required to provide us with this information; however if you do not do so, we cannot
process your appeal. Federal agencies may not conduct or sponsor, and respondents
are not required to respond to a collection of information unless it displays a valid
OMB number.
Although the information which we ask for on this form is almost never used for any
purpose other than the processing of your appeal, the RRB does have the authority to
release some or all of the information without your approval in the following ways:

1) lnformation may be released to an attorney, Congressman's office, labor union or to
the Department of State's embassy or consular offices if they claim to be representing
you at your request.
2) lnformation may be released to other people who are receiving benefits based on the
same railroad retirement account as the one on which you are claiming benefits if the
information might affect their payments from the RRB.
3) lnformation may be released to a person who is receiving benefits on your behalf if the
RRB decides that some medical condition keeps you from receiving your own benefits.

4) lnformation may be released to your last employer to make sure you are eligible to
receive benefits under the Railroad Retirement Act or under the Railroad Unemployment
lnsurance Act.
5) lnformation (including medical records) may be released to people or organizations who are
working for the RRB.
6) lnformation may be released in certain cases for law enforcement purposes and for
court proceedings.
A complete list of the persons, organizations or agencies to which the information you
gave us may be released is published in the Federal Register. The current list is
available in any office of the RRB, if you wish to see it.

ESTIMATED COMPLETION TIME
We think this form takes an average of 20 minutes per response, including the
time for reviewing the instructions, getting the needed data, and reviewing the
completed form. If y o u wish, send comments regarding the accuracy o f our
estimate o r any other aspects of this form, including suggestions for reducing
completion time, t o the Chief of lnformation Management, Railroad Retirement
Board, 844 North Rush Street, Chicago, Illinois 60611-2092 and t o the Office of
M a n a g e m e n t a n d B u d g e t , P a p e r w o r k R e d u c t i o n P r o j e c t (3220-0007),
Washington, DC 20503. Please do not r e t u r n t h i s f o r m t o either o f t h e s e
addresses.

FORM HA-1 (10-98)