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

Form Approved
OMB No. 0960-0277

SOCIAL SECURITY ADMINISTRATION

REQUEST FOR REVIEW OF HEARING DECISION/ORDER

See
(Do not use this form for objecting to a recommended ALJ decision.)
Privacy Act
(Either mail the signed original form to the Appeals Council at the address shown below, or take or mail the
Notice
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
2. CLAIMANT SSN
3. CLAIM NUMBER (If different than SSN)

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 that relates to the period on or before the date of the hearing decision, you must inform the Appeals
Council about it or submit it. If you have a representative, then your representative must help you obtain the evidence unless the
evidence falls under an exception. You may also submit any other additional evidence to the Appeals Council. 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 submit neither evidence nor legal
argument now or within any extension of time the Appeals Council grants, the Appeals Council will take its action based on the evidence
currently in your file.
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.

5. CLAIMANT'S SIGNATURE

DATE

PRINT NAME

6. REPRESENTATIVE'S SIGNATURE DATE

PRINT NAME

ADDRESS

CITY, STATE, ZIP

TELEPHONE NUMBER

FAX NUMBER

ATTORNEY

ADDRESS

NON-ATTORNEY

CITY, STATE, ZIP

TELEPHONE NUMBER

FAX NUMBER

THE SOCIAL SECURITY ADMINISTRATION STAFF WILL COMPLETE THIS PART

7. Request received for the Social Security Administration on

by:

(Date)
(Title)

(Address)

8. Is the request for review received within 65 days of the ALJ's Decision/Dismissal?

(Print Name)
(Servicing FO Code)

(PC Code)

Yes
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.
10. Check one:
11. Check all claim types that apply :
Initial Entitlement
Retirement or survivors
(RSI)
Termination or other
Disability-Worker
(DIWC)
Disability-Widow(er)
(DIWW)
Disability-Child
(DIWC)
SSI Aged
(SSIA)
APPEALS COUNCIL
SSI Blind
(SSIB)
OFFICE OF DISABILITY ADJUDICATION
SSI Disability
(SSID)
AND REVIEW, SSA
Title VIII Only
(SVB)
5107 Leesburg Pike
Title VIII/Title XVI
(SVB/SSI)
FALLS CHURCH, VA 22041 - 3255
Other - Specify:
9. If "No" checked:

Form HA-520-U5 (02-2015) uf (02-2015)
Destroy Prior Editions

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), 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.

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. 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). Send only comments relating
to our time estimate to this address, not the completed form.

Form HA-520-U5 (02-2015) uf (02-2015)