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

CLAIMANT CLAIM NUMBER
(if different from SSN)

CLAIMANT SSN

-

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

-

-

-

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
CLAIMANT
ORTHE
REPRESENTATIVE
SHOULD
SIGN - ENTER ADDRESSES FOR BOTH
ENTER THE
ADDRESSES
FOR
CLAIMANT AND
THE REPRESENTATIVE
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 - OPTIONAL

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

MAILING ADDRESS

MAILING ADDRESS

STATE

CITY

ZIP CODE

STATE

CITY

ZIP CODE

TELEPHONE NUMBER (Include area code)

(

)

-

DATE

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
completed

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 (08-2010) ef (08-2010) Prior Edition May Be Used Until Exhausted

Claims Folder

ADMIISTRATIVE ACTIOS THAT ARE IITIAL DETERMIATIOS
(See G03101.070, G03101.080, 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;
18. Whether completion of or continuation for a
1. Meeting or failing to meet the qualifying and/or
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 (08-2010) ef (08-2010)
reductions.

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0622

TOE 710

(Do not write in this space)

REQUEST FOR RECONSIDERATION
NAME OF CLAIMANT

CLAIMANT SSN

-

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

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

ENTER
FOR
CLAIMANT AND
THE REPRESENTATIVE
EITHER ADDRESSES
THE CLAIMANT
ORTHE
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 - OPTIONAL

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

MAILING ADDRESS

MAILING ADDRESS

STATE

CITY

ZIP CODE

STATE

CITY

ZIP CODE

TELEPHONE NUMBER (Include area code)

(

)

-

DATE

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 (08-2010) ef (08-2010) Prior Edition May Be Used Until Exhausted

Claimant

HOW TO APPEAL YOUR SUPPLEMETAL SECURITY ICOME (SSI)
OR SPECIAL VETERAS BEEFIT (SVB) DECISIO
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. IFORMAL COFERECE:
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 COFERECE:
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.
Privacy Act Statement
Collection and Use of Personal Information
Section 205(a), of the Social SecuritySee
Act as
amended,Privacy
[42 U.S.C.Act
405(a)]
and Title 20
C.F.R. 404.907 - 404.922 and 416.1407 –
Revised
Statement
Attached
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.

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 only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401.
Form SSA-561-U2 (08-2010) ef (08-2010)

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
Privacy Act Statement
Request for Reconsideration
Section 205(a), of the Social Security Act, as amended, and Title 20 C.F.R.404.907-404.922, and
416.1407-416-1422 authorize us to collect this information. We will use this information to help
us determine your entitlement to benefits.
Providing this information is voluntary. However, failing to provide us with all or part of the
requested information may affect our ability to re-evaluate the decision on your claim.
We rarely use the information you supply for any purpose other than for determining problems in
Social Security programs. However, we may use it for the administration and integrity and
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 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 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 System of Records Notices
60-0089, Claims Folder System, and 60-0103, Supplemental Security Income Record and
Special Veterans Benefits. These notices, additional information regarding this form, and
information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at any local Social Security office.