Addendum to the Supporting Statement 0960-0277

Addendum to the Supporting Statement for

Form HA-520

Request for Review of Hearing Decision/Order

20 CFR 404.967-404.981, 20 CFR 416.1467-416.1481

OMB 0960-0277

Terms of Clearance

This information collection is approved as submitted for 3 years. OMB suggests SSA consider and if appropriate, include in its response to the public comment received that the burden estimates are intended to be averages and that it might take individuals more or less time to complete.

SSA Response

Attached is SSA’s response to the public comment.

Revision to the Collection Instrument

We are requesting the following updates and changes to Form HA-520 (OMB 0960-0277), “Request for Review of Hearing Decision/Order.” New language is in bold type below (and highlighted on the revised Form HA-520).

• CHANGE: In the second parentheses under the form’s title, please change the language to read as follows: “(Either mail the signed original form to the Appeals Council at the address shown below or take or mail the signed original to your local Social Security Office, the Department of Veterans Affairs Regional Office in Manila, or any U.S. Foreign Service Post and keep a copy for your records.)”

JUSTIFICATION: This language is being updated to conform to language used on our other appeal forms—e.g., Form HA-501.

• CHANGE: Please use the following configuration for items 1 – 4:

JUSTIFICATION: We believe the above configuration more clearly elicits the needed information than the configuration used on the current Form HA-520.

• CHANGE: Below item 5, please delete the word “now” from the end of the second sentence under “ADDITIONAL EVIDENCE” and insert a new sentence to read as follows: “This will ensure that the Appeals Council has the opportunity to consider the additional evidence before taking its action.”

JUSTIFICATION: We are changing this instruction to illustrate more clearly the advantages of submitting additional evidence with Form HA-520.

• CHANGE: Please capitalize the instruction after “IMPORTANT” under “ADDITIONAL EVIDENCE” and delete the word “claim” so that it appears thus: “IMPORTANT: WRITE YOUR SOCIAL SECURITY NUMBER ON ANY LETTER OR MATERIAL YOU SEND US.” Also add a new sentence after this one in the same typeface and in all capitals, which says, “IF YOU RECEIVED A BARCODE FROM US, THE BACODE SHOULD ACCOMPANY THIS DOCUMENT AND ANY OTHER MATERIAL YOU SUBMIT TO US.”

JUSTIFICATION: We wish to emphasize the importance of clearly identifying any material submitted to SSA. Additionally, we wish to update the language to reflect instructions related to our electronic disability folder process.

• CHANGE: Please add a “Date” field somewhere in item 6. The HA-501 uses the configuration below, but we would like to retain the “Print Name” field on the existing HA-520.

JUSTIFICATION: We are requesting this change to make Form HA-520 more consistent with our other appeal forms.

• CHANGE: On the reverse of the form, in the third paragraph, please insert “Department of” before “Veterans Affairs Regional Office in Manila.”

JUSTIFICATION: We are making this change to reflect the correct name of this agency.

Other Minor Revisions to the Collection Instrument

SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the first page of the form.

3