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)
9. (REPRESENTATIVE'S SIGNATURE/NAME)
8. (CLAIMANT'S SIGNATURE)
ADDRESS

(ADDRESS)

STATE

CITY

FAX NUMBER

TELEPHONE NUMBER

(

)

ZIP CODE

-

(

)

-

-

ATTORNEY;

NON-ATTORNEY;
STATE

CITY

TELEPHONE NUMBER

(

)

ZIP CODE

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):

RSI only

No

Title II Disability-worker or child only
Title II Disability-Widow(er) only

14. Check one:

Initial Entitlement Case
Disability Cessation Case
Other Postentitlement Case
HO on
16. HO COPY SENT TO:

SSI Aged only
SSI Blind only
SSI Disability only

CF Attached:
Title II;
Title XVI;
Title VIII;
Title II CF held in FO
Electronic Folder
CF requested
Title II;
Title VIII;
Title XVI;
(Copy of email or phone report attached)
HO on
17. CF COPY SENT TO:
CF Attached:
Other Attached:

Title II;

Form HA-501-U5 (02-2011) ef (02-2011)
Destroy Prior Editions

Title XVI;

Title XVIII

T XVIII;
T XVIII

SSI Aged/Title II
SSI Blind/Title II
SSI Disability/Title II
Title XVIII
Title VIII Only
Title VIII/Title XVI
Other - Specify:

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

(RSI)

(DIWC)
(DIWW)
(SSIA)
(SSIB)
(SSID)
(SSAC)
(SSBC)
(SSDC)
(HI/SMI)
(SVB)
(SVB/SSI)

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 the
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 investigate 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.
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 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-501-U5 (02-2011) ef (02-2011)