Form HA-520 Request for Review of Hearing Decision/Order

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 ALJ decision.)
(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.)

1. CLAIMANT NAME

CLAIMANT SSN

2. WAGE EARNER NAME, IF DIFFERENT

3. CLAIMANT CLAIM NUMBER, IF DIFFERENT

-

See Privacy Act Notice

-

4. 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. This will ensure that the Appeals Council has the opportunity to consider the additional evidence
before taking its action. 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 NUMBER ON ANY LETTER OR MATERIAL YOU SEND US. IF YOU RECEIVED A BARCODE
FROM US, THE BARCODE SHOULD ACCOMPANY THIS DOCUMENT AND ANY OTHER MATERIAL YOU SUBMIT TO US.
SIGNATURE BLOCKS: You should complete No. 5 and your representative (if any) should complete No. 6. 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. 6.

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
5. CLAIMANT'S SIGNATURE
6. REPRESENTATIVE'S SIGNATURE

PRINT NAME

ADDRESS

ADDRESS

(CITY, STATE, ZIP CODE)

(CITY, STATE, ZIP CODE)

TELEPHONE NUMBER

FAX NUMBER

(

(

)

-

)

TELEPHONE NUMBER

-

(

)

NON-ATTORNEY

ATTORNEY

PRINT NAME

FAX NUMBER

-

(

)

-

THE SOCIAL SECURITY ADMINISTRATION STAFF WILL COMPLETE THIS PART
by:

7. Request received for the Social Security Administration on
(Date)

(Title)

(Print Name)

(Address)

(Servicing FO Code)

8. Is the request for review received within 65 days of the ALJ's Decision/Dismissal?
9. If "No" checked:

10. Check one:

Yes

(PC Code)

No

(1) attach claimant's explanation for delay; and
(2) attach copy of appointment notice, letter or other pertinent material or information in the Social Security Office.
11. Check all claim types that apply :

Initial Entitlement
Termination or other

APPEALS COUNCIL
OFFICE OF DISABILITY ADJUDICATION AND
REVIEW, SSA
5107 Leesburg Pike
FALLS CHURCH, VA 22041 - 3255

Form HA-520-U5 (07-2011) ef (07-2011)
Destroy Prior Editions

Retirement or survivors
Disability-Worker
Disability-Widow(er)
Disability-Child
SSI Aged
SSI Blind
SSI Disability
Title VIII Only
Title VIII/Title XVI
Other - Specify:

(RSI)
(DIWC)
(DIWW)
(DIWC)
(SSIA)
(SSIB)
(SSID)
(SVB)
(SVB/SSI)

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

Privacy Act Statement
Request for Review of Hearing Decision/Order
Sections 205(a), 702, 1631 (e)(1)(a) and (b), and 1869(b)(1) and (c) of the Social Security Act and
Public Law 106-169 (sections 809(a)(1) and 251 (a)), as amended, authorize us to collect this
information. The information you provide on this form is used to complete our claims process. Your
response is voluntary. However, failure to provide all or part of the requested information may affect
the continued processing of your claim.
We rarely use the information provided 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 of Social Security records
(e.g., to the Government Accountability Office, the General Services Administration, the
National Archives and 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, and investigative activities necessary to ensure the
integrity and improvement of SocialSee
Security
Programs.
revised

Privacy Act
Statement
below. Computer matching programs
We may also use this information in computer
matching programs.
compare our records with those of 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 of delinquent debts
under these programs.
A complete list of routine uses for this information is available in Systems of Records Notices entitled,
Administrative Law Judge Working File on Claimant Cases (60-0005), Storage of Hearing Records:
Tape Cassettes and Audiograph Discs (60-0006), and Hearing Office Tracking System of Claimant
Cases (60-0010), Social Security Administration, Office of Disability Adjudication and Review. These
notices, additional information about this form, and information regarding our programs and systems
are available online at www.socialsecurity.gov or at your 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 (OMB) control
number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and
answer the questions. 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 (07-2011) ef (07-2011)

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 702, 1631(e), and 1869(b) and (c) of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you provide to complete
our claims process.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent the continued processing of your claim.
We rarely use the information you supply for any purpose other than to complete our claims
process. However, we may use the information for the administration of our programs including
sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices 60-0005, entitled Administrative Law
Judge Working Files and 60-0089, entitled Claims Folder. Additional information about these
and other system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.