Form SSA-561-U2 Request for Reconsideration

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0622

TOE 710

(Do not write in this space)

REQUEST FOR RECONSIDERATION
NAME OF CLAIMANT

NAME OF WAGE EARNER OR SELF-EMPLOYED
PERSON (If different from claimant.)

CLAIMANT CLAIM NUMBER
(if different from SSN)

CLAIMANT SSN

-

-

-

-

SUPPLEMENTAL SECURITY INCOME (SSI) OR
SPECIAL VETERANS BENEFITS (SVB) CLAIM
NUMBER

-

-

SPOUSE'S SOCIAL SECURITY NUMBER
(Complete ONLY in SSI cases)

SPOUSE'S NAME (Complete ONLY in SSI cases)

-

-

CLAIM FOR (Specify type, e.g., retirement, disability, hospital /medical, SSI, SVB, etc.)

I do not agree with the determination made on the above claim and request reconsideration. My reasons are:

SUPPLEMENTAL SECURITY INCOME OR SPECIAL VETERANS BENEFITS RECONSIDERATION ONLY
(See the three ways to appeal in the How To Appeal Your Supplemental Security Income (SSI) Or Special Veterans Benefit (SVB) Decision instructions.)

"I want to appeal your decision about my claim for Supplemental Security Income (SSI) or Special Veterans Benefits
(SVB). I've read about the three ways to appeal. I've checked the box below."

Case Review

Informal Conference

Formal Conference

EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH
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.
CLAIMANT SIGNATURE

SIGNATURE OR NAME OF CLAIMANT'S REPRESENTATIVE
NON-ATTORNEY
ATTORNEY

MAILING ADDRESS

MAILING ADDRESS

STATE

CITY

ZIP CODE

STATE

CITY

ZIP CODE

-

(

)

-

DATE

TELEPHONE NUMBER (Include area code)

TELEPHONE NUMBER (Include area code)

-

(

)

DATE

-

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION
See list of initial determinations
1. HAS INITIAL DETERMINATION
BEEN MADE?

2. CLAIMANT INSISTS
ON FILING

YES

NO

3. IS THIS REQUEST FILED TIMELY?
(If "NO", attach claimant's explanation for delay and attach any pertinent letter, material, or
information in Social Security office.)

YES

NO

YES

NO

RETIREMENT AND SURVIVORS RECONSIDERATIONS ONLY (CHECK ONE) REFER TO (GN 03102.125)

NO FURTHER DEVELOPMENT REQUIRED

SOCIAL SECURITY OFFICE ADDRESS

(GN 03102.300)

REQUIRED DEVELOPMENT ATTACHED
REQUIRED DEVELOPMENT PENDING, WILL FORWARD OR ADVISE STATUS
WITHIN 30 DAYS
ROUTING
INSTRUCTIONS
(CHECK ONE)

DISABILITY DETERMINATION
SERVICES (ROUTE WITH
DISABILITY FOLDER)

ODO, BALTIMORE

PROGRAM SERVICE CENTER
OIO, BALTIMORE
OEO, BALTIMORE

DISTRICT OFFICE
RECONSIDERATION
CENTRAL PROCESSING
SITE (SVB)

NOTE: 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.
Form SSA-561-U2 (9-2007) ef (10-2009)

Prior Edition May Be Used Until Exhausted

Claims Folder

ADMINISTRATIVE ACTIONS THAT ARE INITIAL DETERMINATIONS
(See GN03101.070, GN03101.080, and SI04010.010)
NOTE: These lists cover the vast majority of
administrative actions that are initial
determinations. However, they are not all
inclusive.

Title II
1.
2.
3.
4.
5.

Title XVI
1. Eligibility for, or the amount of, Supplemental
Security Income benefits;
2. Suspension, reduction, or termination of
Supplemental Security Income benefits;
3. Whether an overpayment of benefits must be
repaid;
4. Whether payments will be made, on claimant's
behalf to a representative payee, unless the
claimant is under age 18, legally incompetent,
or determined to be a drug addict or alcoholic;
5. Who will act as payee if we determine that
representative payment will be made;
6. Imposing penalties for failing to report
important information;
7. Drug addiction or alcoholism;
8. Whether claimant is eligible for special SSI cash
benefits;
9. Whether claimant is eligible for special SSI
eligibility status;
10. Claimant's disability; and
11. Whether completion of or continuation for a
specified period of time in an appropriate
vocational rehabilitation program will
significantly increase the likelihood that
claimant will not have to return to the disability
benefit rolls and thus, whether claimant's
benefits may be continued even though he or
she is not disabled.

Entitlement or continuing entitlement to benefits;
Reentitlement to benefits;
The amount of benefit;
A recomputation of benefit;
A reduction in disability benefits because benefits
under a worker's compensation law were also
received;
6. A deduction from benefits on account of work;
7. A deduction from disability benefits because of
claimant's refusal to accept rehabilitation services;
8. Termination of benefits;
9. Penalty deductions imposed because of failure to
report certain events;
10. Any overpayment or underpayment of benefits;
11. Whether an overpayment of benefits must be repaid;
12. How an underpayment of benefits due a deceased
person will be paid;
13. The establishment or termination of a period of
disability;
14. A revision of an earnings record;
15. Whether the payment of benefits will be made, on
the claimant's behalf to a representative payee,
unless the claimant is under age 18 or legally
incompetent;
16. Who will act as the payee if we determine that
NOTE: Every redetermination which gives an
representative payment will be made;
individual the right of further review
17. An offset of benefits because the claimant previously
constitutes an initial determination.
received Supplemental Security Income payments
Title VIII (See VB 02501.035)
for the same period;
1. Meeting or failing to meet the qualifying and/or
18. Whether completion of or continuation for a
entitlement factors for special veterans benefits
specified period of time in an appropriate vocational
(SVB);
rehabilitation program will significantly increase the
2.
Reduction,
suspension or termination of SVB
likelihood that the claimant will not have to return to
payments;
the disability benefit rolls and thus, whether the
3. Applicability of a disqualifying event prior to
claimant's benefits may be continued even though
SVB entitlement;
the claimant is not disabled;
4. Administrative actions in SVB cases similar to
19. Nonpayment of benefits because of claimant's
those listed under Title II--items 3, 4, 10, 11 &
confinement for more than 30 continuous days in a
16.
jail, prison, or other correctional institution for
Title XVIII
conviction of a criminal offense;
1. Entitlement to hospital insurance benefits
20. Nonpayment of benefits because of claimant's
and to enrollment for supplementary
confinement for more than 30 continuous days in a
medical insurance benefits;
mental health institution or other medical facility
2. Disallowance (including denial of
because a court found the individual was not guilty
application for HIB and denial of
for reason of insanity; a court found that he/she was
application for enrollment for SMIB);
incompetent to stand trial or was unable to stand trial
3. Termination of benefits (including
for some other similar mental defect; or, a court
termination of entitlement to HI and SMI).
found that he/she was sexually dangerous.
4. Initial determinations regarding Medicare
Part B income-related premium subsidy
Form SSA-561-U2 (9-2007) ef (10-2009)
reductions.

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0622

TOE 710

(Do not write in this space)

REQUEST FOR RECONSIDERATION
NAME OF CLAIMANT

NAME OF WAGE EARNER OR SELF-EMPLOYED
PERSON (If different from claimant.)

CLAIMANT SSN

-

CLAIMANT CLAIM NUMBER
(if different from SSN)

-

-

SUPPLEMENTAL SECURITY INCOME (SSI) OR
SPECIAL VETERANS BENEFITS (SVB) CLAIM
NUMBER

-

-

-

SPOUSE'S SOCIAL SECURITY NUMBER
(Complete ONLY in SSI cases)

SPOUSE'S NAME (Complete ONLY in SSI cases)

-

-

CLAIM FOR (Specify type, e.g., retirement, disability, hospital/medical, SSI, SVB, etc.)

I do not agree with the determination made on the above claim and request reconsideration. My reasons are:

SUPPLEMENTAL SECURITY INCOME OR SPECIAL VETERANS BENEFITS RECONSIDERATION ONLY
(See the three ways to appeal in the How To Appeal Your Supplemental Security Income (SSI) Or Special Veterans Benefit (SVB) Decision instructions.)

"I want to appeal your decision about my claim for Supplemental Security Income (SSI) or Special Veterans Benefits
(SVB). I've read about the three ways to appeal. I've checked the box below."

Case Review

Informal Conference

Formal Conference

EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH
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.
CLAIMANT SIGNATURE

SIGNATURE OR NAME OF CLAIMANT'S REPRESENTATIVE
NON-ATTORNEY
ATTORNEY

MAILING ADDRESS

MAILING ADDRESS

STATE

CITY

ZIP CODE

STATE

CITY

ZIP CODE

-

(

)

-

DATE

TELEPHONE NUMBER (Include area code)

TELEPHONE NUMBER (Include area code)

(

-

)

DATE

-

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION
See list of initial determinations
1. HAS INITIAL DETERMINATION
BEEN MADE?

2. CLAIMANT INSISTS
ON FILING

YES

NO

3. IS THIS REQUEST FILED TIMELY?
(If "NO", attach claimant's explanation for delay and attach any pertinent letter, material, or
information in Social Security office.)

YES

NO

YES

NO

RETIREMENT AND SURVIVORS RECONSIDERATIONS ONLY (CHECK ONE) REFER TO (GN 03102.125)

NO FURTHER DEVELOPMENT REQUIRED

SOCIAL SECURITY OFFICE ADDRESS

(GN 03102.300)

REQUIRED DEVELOPMENT ATTACHED
REQUIRED DEVELOPMENT PENDING, WILL FORWARD OR ADVISE STATUS
WITHIN 30 DAYS
ROUTING
INSTRUCTIONS
(CHECK ONE)

DISABILITY DETERMINATION
SERVICES (ROUTE WITH
DISABILITY FOLDER)

ODO, BALTIMORE

PROGRAM SERVICE CENTER
OIO, BALTIMORE
OEO, BALTIMORE

DISTRICT OFFICE
RECONSIDERATION
CENTRAL PROCESSING
SITE (SVB)

NOTE: 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.
Form SSA-561-U2 (9-2007) ef (10-2009)

Prior Edition May Be Used Until Exhausted

Claimant

HOW TO APPEAL YOUR SUPPLEMENTAL SECURITY INCOME (SSI)
OR SPECIAL VETERANS BENEFIT (SVB) DECISION
There are three different ways to appeal. You can pick the appeal that fits your case. You can have a lawyer,
friend, or someone else help you with your appeal.
Here are the three ways to appeal:
1. CASE REVIEW:
You can give us more facts to add to your file. Then we'll decide your case again. You don't meet with the
person who decides your case.
You can pick this kind of appeal in all cases.
2. INFORMAL CONFERENCE:
You'll meet with the person who will decide your case. You can tell that person why you
think you're right. You can give us more facts to help prove you're right. You can bring other people to
help explain your case.
You can pick this kind of appeal in all SSI cases except two. You can't have it if we turned down your SSI
application for medical reasons or because you're not blind. Also you can't have it if we're giving you SSI
but you disagree with the date we said you became blind or disabled. In SVB cases, you can pick this kind
of appeal only if we're stopping or lowering your SVB payment.
3. FORMAL CONFERENCE:
This is a meeting like an informal conference. Plus, we can make people come to help prove you're right.
We can do this even if they don't want to help you. You can question these people at your meeting.
You can pick this kind of appeal only if we're stopping or lowering your SSI or SVB payment. You can't
get it in any other case.
Now you know the three kinds of appeals. You can pick the one that fits your case. Then fill out this form.
We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer. We can give you the
names of these groups.
NOTE: DON'T FILL OUT THIS FORM IF WE SAID WE'LL STOP YOUR DISABILITY
CHECK FOR MEDICAL REASONS OR BECAUSE YOU'RE NO LONGER BLIND.
WE'LL GIVE YOU THE RIGHT FORM (SSA-789-U4) FOR YOUR APPEAL.
The information on this form is authorized by regulation (20 CFR 404.907 - 404.921 and 416.1407 -416.1421)
and Public Law 106-169 (section 809(a)(1) of section 251(a)). While your response to these questions is
voluntary, the Social Security Administration cannot reconsider the decision on this claim unless the
information is furnished.
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
See
revised
take about 8 minutes to read the instructions, gather the
facts,
and answer the questions. SEND THE
Paperwork
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under
U.S. Government agencies in your telephone directory
or you Act
mayand
call Social Security at 1-800-772-1213
Reduction
(TTY 1-800-325-0778). You may send comments on Privacy
our time Act
estimate above to : SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating
to ourBelow.
time estimate to this address, not the
Statement
completed form.
Form SSA-561-U2 (9-2007) ef (10-2009)

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 8
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 Reconsideration, SSA-561-U2
Privacy Act Statement
Collection and Use of Personal Information

Section 205(a), of the Social Security Act as amended, [42 U.S.C. 405(a)] and
Title 20 C.F.R. 404.907 - 404.922 and 416.1407 – 416.1422 authorize us to collect this
information. We will use the information you provide to help us determine your
entitlement to benefits. The information you provide on this form is voluntary.
However, we cannot reconsider the decision on your claim unless you furnish this
information.
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 for 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 agencies can be used to
establish or verify a person’s eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records
Notice entitled Claims Folder System 60-0089. The notice, additional information
regarding this form, and information regarding our systems and programs, are available
on-line at www.socialsecurity.gov or at any local Social Security office.