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

UNITED STATES OF AMERICA
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 RAILROAD UNEMPLOYMENT INSURANCE ACT

RRB CLAIM NUMBER
(R.R.A. Appeals Only)
PRINT ADDRESS (Number, Street/Apt. No., P.O. Box)

TELEPHONE NO.
AREA CODE

(
IMPORTANT: PLEASE READ FORM HA-2
BEFORE COMPLETING THIS FORM

)

STATE

CITY

ZIP CODE

Before completing this form read the information contained on the back of this form.
COMPLETE EITHER ITEM A OR B BELOW:

A.
B.

J
J

I hereby appeal the reconsideration decision reported in a letter dated ______________________________
I hereby 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)

I certify that the information I have provided is true to the best of my knowledge. I know that if I have made a false or fraudulent
statement on this form or with any of the supporting evidence submitted, I am committing a crime which is punishable under Federal law
by fine or imprisonment or both.
THIS FORM SHOULD BE SENT TO THE BUREAU OF HEARINGS AND APPEALS, RAILROAD 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:
Name of
Representative ______________________________________

SIGNATURE OF
CLAIMANT________________________________________
DATE SIGNED _____________________________________

Address ____________________________________________
___________________________________________________
Phone No. (

J

IF THIS APPEAL IS FILED BY A PERSON OTHER THAN
CLAIMANT, STATE RELATIONSHIP TO THE CLAIMANT
BELOW:

) ________________________________
Attorney

J Non-Attorney

FORM HA-1 (08-07) DESTROY PREVIOUS EDITIONS

(EXECUTOR, ADMINISTRATOR, GUARDIAN, ETC.)

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 Insurance 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) Information 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) Information 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) Information 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) Information 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
Insurance Act.
5) Information (including medical records) may be released to people or organizations who are
working for the RRB.
6) Information 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 you wish, send comments regarding the accuracy of our
estimate or any other aspects of this form, including suggestions for reducing
completion time, to the Chief of Information Management, Railroad Retirement
Board, 844 North Rush Street, Chicago, Illinois 60611-2092 and to the Office of
Management and Budget, Paperwork Reduction Project (3220-0007),
Washington, DC 20503. Please do not return this form to either of these
addresses.

FORM HA-1 (08-07)