Public Safety Officers' Appeal Request Application

Section/Heading	Subheading	Modal?	Question	Field Type	Answer Choices (If applicable)	Required/Not Required	Instructional Text
	Filing Capacity
			In which capacity are you filing this appeal request?	Radio	Claimant/Authorized Representative	Required
			Are you represented by an Authorized Representative?	Radio	No, I am not represented by an Authorized Representative; Yes, I am represented by an Authorized Representative.	Only Required if claimant is chosen as the answer to the previous question.
Authorized Representative Information							Provide the contact information for the Authorized Representative.
			Authorized Representative Name	Text Box	NA	Only required if "Authorized Representative" (In Row 5 Column E) or "Yes, I am represented by an Authorized Representative" is chosen as a response to the previous question (Row 6 Column E).
			Authorized Representative Phone Number	Text Box	NA	Only required if "Authorized Representative" (In Row 5 Column E) or "Yes, I am represented by an Authorized Representative" is chosen as a response to the previous question (Row 6 Column E).
			Authorized Representative Type	Radio	Attorney, Other	Only required if "Authorized Representative" (In Row 5 Column E) or "Yes, I am represented by an Authorized Representative" is chosen as a response to the previous question (Row 6 Column E).
			Describe "other" here	Text Box	NA	Only required if "Other" chosen as a response to the previous question.
Claimant Information	Enter information about the Claimant
			Claimant First Name	Text Box	NA	Required
			Claimant Middle Name	Text Box	NA	Not Required
			Claimant Last Name	Text Box	NA	Required
	Enter information about the Claim you are appealing
			Determination Type	Radio	PSOB Office Determination, Hearing Officer Determination	Required
			Claim Number	Text Box	NA	Required
	Enter Information about the Public Safety Officer
			Public Safety Officer First Name	Text Box	NA	Required
			Public Safety Officer Last Name	Text Box	NA	Required
			Public Safety Officer Employing Agency	Text Box	NA	Required
APPEAL REQUEST PREVIEW	Please Review and Confirm						The following is a summary of the information you have entered. Please review and make any necessary changes to this page before submitting your Appeal Request.
Required Documents							Based on your responses, a customized checklist has been generated. The following required documents must be uploaded for the application to be considered complete. If you have any questions, please contact the PSOB Customer Resource Center at 1-888-744-6513 or [email protected].
			Association	Static Text Box	NA	Auto filled
			Document Type	Static Text Box	NA	Auto filled
			Date Uploaded	Static Text Box	NA	Auto filled
			Instructions	Static Text Box	NA	Auto filled	All doc instructions are located in the "Required Documents and Instructions" tab
			Review Status	Static Text Box	NA	Auto filled
			Add document clarifying notes if necessary.	Text Box	NA	Not Required
			Missing Document Justification	Text Box	NA	Required only if a required document is not uploaded
Missing Documents							Your appeal request is missing one or more required documents needed to successfully submit your appeal request. Please go to the previous screen to review the list of required documents, to upload all required documents or to provide an explanation of why a document is missing.
	CERTIFICATION OF APPLICATION		Check the box to confirm that you have read and understand this Certification, which will serve as an electronic signature by or on behalf of the Claimant.	Checkbox	NA	Required	The information provided will be used by the Department of Justice to determine eligibility of a Claimant for PSOB Program benefits. To verify eligibility for benefits, the information provided is subject to investigation and may be disclosed to federal, state, tribal, and local agencies to verify eligibility for benefits. If the Department of Justice receives adverse information regarding a Claimant’s eligibility, an information of record may be disclosed as necessary to affected persons and federal, state, tribal, and local agencies, including those persons or agencies challenging eligibility. I certify that all of the information provided is correct and complete to the best of my knowledge. I know of no facts or circumstances that would render the person identified here as ineligible for the benefit. I understand that knowingly and willfully making a false or incomplete statement or failing to fully disclose pertinent information concerning this claim may be grounds for non-payment of benefits or for prosecution for a false statement under 18 U.S.C. § 1001. Checking the box below asserts that you have read and understand this Certification, and will be treated as an electronic signature by or on behalf of the Claimant. If you are ready to submit your Appeal Request, click the ‘Next/Save” button. If you need to make changes in your application, click the “Previous” button.
APPEAL REQUEST FINAL REVIEW FORM	Please Review and Confirm						This final review form serves as the version of the Appeal Request you are about to submit.  If you wish to make edits, return to the editable preview screen to do so.
Appeal Request Submitted							You have successfully submitted your Appeal Request, the initial step in appealing the decision on your benefits claim. Please note, Appeal Requests must be received by the PSOB Office within 33 days from the date on the notification letter. If you are filing an appeal beyond 33 days, an extension may be needed. Please visit <Filing Extension URL> to learn more. An Appeals Specialist will review your appeal request to confirm your eligibility to appeal.  If you have questions about your Appeal Request, please do not hesitate to call the PSOB Customer Resource Center at 1-888-744-6513 Monday through Friday between 8:00 AM - 4:30 PM Eastern Standard Time, or by submitting a message to the PSOB Office using the Messaging Center located on the MyPSOB page.