Form HA-501 Request for Hearing By Administrative Law Judge

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 NAME

CLAIMANT SSN

3. CLAIMANT CLAIM NUMBER, IF DIFFERENT

4. SPOUSE'S NAME, IF NOT WAGE EARNER

-

-

-

-

2. WAGE EARNER NAME, IF DIFFERENT
SPOUSE'S CLAIM NUMBER OR SSN

-

-

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 Social Security Administration's Office of Disability Adjudication and Review or the 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.
6. I have additional evidence to submit.

Yes

7. Do not complete if the appeal is a Medicare
issue.
Check one of the blocks:

No

Name and address of source of additional evidence:

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)

(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) unless you are appealing a Medicare issue.
Regardless of the issue you are appealing, 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 VIII;
Title II CF held in FO
Electronic Folder
CF requested
Title II;
Title XVI;
Title VIII;
(Copy of email or phone report attached)
HO on
17. CF COPY SENT TO:
CF Attached:
Other Attached:

Title II;

Form HA-501-U5 (5-2007) ef (3-2008)
Destroy Prior Editions

Title XVI;

Title XVIII

T XVIII;
T XVIII

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)

Title XVIII

(HI/SMI)

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)) and
Section 1839(i) of the Act (P.L. 108-173) 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 inSee
touch
with any Social Security office, the Veterans
revised
Affairs Regional Office in Manila,
or any U.S. Foreign Service post.
Paperwork
Reduction Act and
We may also use the information
youAct
give us when we match records by
Privacy
computer. Matching programs
compare our
records with those of other Federal,
Statements
below.
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 (5-2007) ef (3-2008)

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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. 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
www.socialsecurity.gov. 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 1800-325-0778). 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.

Request for Hearing by Administrative Law Judge, Form HA-501-U5
Privacy Act Statement
Collection and Use of Personal Information
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), and 1869(b)(1) and (c) (42
U.S.C. 1395ff) of the Social Security Act authorizes us to collect this information.
We will use the information you provide to continue processing your claim. The
information you provide on this form is voluntary. However, failure to provide all or
part of the requested information could prevent us from making an accurate and
timely decision on your claim.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. 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, General
Services Administration, National Archives Records Administration, 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 investigative 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 and administered benefit
programs for repayment of payments or delinquent debts under these programs. The
law allows us to do this even if you do not agree to it.
A complete list of routine uses for this information is available in our System of
Records Notice entitled, Claims Folder System, 60-0089. This notice, additional
information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at any Social Security
office.