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 decision.)
Privacy Act
(Either mail the signed original form to the Appeals Council at the address shown below, or take or mail
Notice
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 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. 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.
DATE
6. REPRESENTATIVE'S SIGNATURE DATE
5. CLAIMANT'S SIGNATURE
PRINT NAME

PRINT NAME
MAILING ADDRESS

CITY, STATE, ZIP

TELEPHONE NUMBER

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)

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

(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
Termination or other

APPEALS COUNCIL

Retirement or survivors
Disability-Worker
Disability-Widow(er)
Disability-Child
SSI Aged

(RSI)
(DIWC)
(DIWW)
(DIWC)
(SSIA)

OFFICE OF APPELATE OPERATIONS,
SSA
5107 Leesburg Pike
FALLS CHURCH, VA 22041 - 3255
Form HA-520-U5 (01-2016) UF (01-2016)
Destroy Prior Editions

SSI Blind
SSI Disability
Title VIII Only
Title VIII/Title XVI
Other - Specify:

(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), 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.govor 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 regarding this burden estimate or any other aspect of this collection, including
suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
See Revised PRA Statement Attached

Form HA-520-U5 (01-2016) UF (01-2016)