HA-520 (old version)

Form Approved
OMB No . 0960-0277

SOCIAL SECURITY ADMINISTRATION/OFFICE OF DISABILITY ADJUDICATION AND REVIEW

REQUEST FOR REVIEW OF HEARING DECISION/ORDER
(Do not use this form for objecting to a recommended AU decision .)

See Privacy Act Notice

(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.)

1 . CLAIMANT

2 WAGE EARNER IF DIFFERENT

3. SOCIAL SECURITY CLAIM NUMBER

4 . SPOUSE'S NAME AND SOCIAL SECURITY NUMBER
(Complete ONLY in Supplemental Security Income Case)

5 . I request that the Appeals Council review the Administrative Law Judge's action on the above claim because :

ADDITIONAL EVIDENCE
If you have additional evidence submit it with this request for review . If you need additional time to submit evidence or legal argument, you must
request an extension of time in writing now. If you request an extension of time, you should explain the reason(s) you are unable to submit the evidence
or legal argument now . If you neither submit evidence or legal argument now nor within any extension of time the Appeals Council grants, the Appeals
Council will take its action based on the evidence of record .
IMPORTANT : Write your Social Security Claim Number on any letter or material you send us.
SIGNATURE BLOCKS : You should complete No . 6 and your representative (if any) should complete No . 7 . If you are represented and your
representative is not available to complete this form, you should also print his or her name, address, etc . i n No . 7 .
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 rue and correct o the best of my knowledqe .
DATE
Q ATTORNEY
6 . CLAIMANT'S SIGNATURE
7 . REPRESENTATIVE'S SIGNATURE
0 NON-ATTORNEY
PRINT NAME

PRINT NAME

ADDRESS

ADDRESS

(CITY, STATE, ZIP CODE)

(CITY, STATE, ZIP CODE)

TELEPHONE NUMBER

FAX NUMBER

FAX NUMBER

TELEPHONE NUMBER

THE SOCIAL SECURITY ADMINISTRATION T FF WILL COMPLETE ; THIS PART
by:

8 . Request received for the Social Security Administration on

- (Pitt Name)

(Date)
INe) .

(Address)

3. Is the request for review received within 5 days of

(I
ALJ's Decision/Dismis

I?

icing.

Q Yes

Code) . . . .

No

10 . If "No" checked : (1) attach claimants explanation for delay, :and
(2) attach copy of appointment notice, letter or other pertinent material or information i
11 . Check one:

Q Initial Entitlement

0 Retirement or survivors
Q Disability-Worker

o Disability-Widow(er)

FALLS CHURCH, VA 22041-'32 5

Form HA-520-U5 (4-2009) of (4-2009)
Destroy Prior Editions

IS

u

0 ce.

12 . Check all claim, types that apply :..

(] Termination or other

APPEALS COUNCIL
OFFICE OF DISABILITY ADJUDI ATI
REVIEW, SSA
5107 L sburg Pike

So

AND

Q Disability-Child
Q SSI Aged
Disci
Q'l SSI Blind
SSI Disability
Title Vill Only
Q Title VIIUTi0e XVl
Q Other- Specify:

8

(RSI)
(DIWC)
(DIWW)

(DIWC) _'
(SSIA)
(SSIB)
(SSID)
(SVB)
(SVB/SSI)

TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS

PAPERWORKIPRIVACY 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 . SEND THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE . The office is listed under U. S . Government
agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778) . 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.

Form HA-520-U5 (4-2009) of (4-2009)