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
Privacy Act
Notice

(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
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:

☐ Please grant me an extension of time to submit evidence or argument.

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. The
Appeals Council will consider additional evidence subject to the conditions specified in our rules which the Appeals Council will
consider under our rules. 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
6. REPRESENTATIVE’S SIGNATURE
DATE
PRINT NAME
ADDRESS
TELEPHONE NUMBER

PRINT NAME
CITY, STATE, ZIP
FAX NUMBER

☐ ATTORNEY

ADDRESS
TELEPHONE NUMBER

☐ NON-ATTORNEY

CITY, STATE, ZIP
FAX NUMBER

THE SOCIAL SECURITY ADMINISTRATION STAFF WILL COMPLETE THIS PART
7. Request received for the Social Security Administration on______________ by:_______________________________
(Date)
(Print Name)

(Title)
(Address)
(Servicing FO Code)
(PC Code)8. Is the request for review received within 65 days of the ALJ’s Decision/Dismissal?
☐ Yes ☐ No
☐ (1) attach claimant’s explanation for delay; and
9. If “No”
☐ (2) attach copy of appointment notice, letter or other pertinent material or information in the
checked:
Social Security Office.
10. Check one:
11. Check all claim types that apply:
Retirement or survivors
(RSI)
☐ Initial Entitlement
Disability-Worker
(DIWC)
☐ Termination or other
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:
Form HA-520-U5 (01-2016) UF (01-2016)
TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY
Destroy Prior Editions
FOR YOUR RECORDS

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1631(d)(1) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent a review by the Appeals Council of an administrative law judge’s
hearing decision or dismissal of a hearing request.
We will use the information to document the claimant’s request for a review. We may also share
the information for the following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA
in the efficient administration of its programs; and,
2. To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representatives or representative payee to the extent necessary to pursue
Social Security claims.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORNs) 60-0005, entitled Administrative Law Judge Working on Claimant Cases and 60-0089,
entitled Claims Folders System. Additional information and a full listing of all our SORNs are
available on our website at www.socialsecurity.gov/foia/bluebook.

2/15/2017 10:55 AM