HA-1 (xx-xx) - Pro Claimant Appeal Under the Railroad Retirement Act or Rai

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0007

PROPOSED

CLAIMANT APPEAL UNDER THE RAILROAD RETIREMENT ACT OR
RAILROAD UNEMPLOYMENT INSURANCE ACT
IMPORTANT: Read the “Important Notice” on the
next page and the accompanying Form
HA-2 before completing this form.
RETURN the completed form to:

RRB Claim Number
Print Name (First, Middle Initial, Last)

Print Address (Number, Street/Apt. No., Po Box)

Bureau of Hearings and Appeals
Railroad Retirement Board
844 North Rush Street
Chicago, Illinois 60611-1275

City

Complete either Item A or B 



ZIP Code

Telephone Number

(



State

)

A. I hereby appeal the reconsideration decision reported in a
letter dated
.
B. I hereby appeal the Hearings Officer’s decision reported in a
letter dated
.

This appeal is based on what I believe to be mistakes of fact or errors of law. Details of these mistakes are as
follows.

(Attach additional sheets if necessary.)




I have no additional evidence.
I intend to submit additional evidence as follows:

I certify that the information I have provided is true to the best of my knowledge. I know that if I have made a
false or fraudulent statement on this form or with any of the supporting evidence submitted, I am committing a
crime which is punishable under Federal law by fine or imprisonment or both.
IF CLAIMANT IS REPRESENTED

Signature of Claimant

Name of Representative
Address

Date Signed

If this appeal is filed by a person other than the
claimant, state below the relationship to the claimant.
(For example, Executor, Administrator, Guardian, etc.)
Telephone No.

(



)
Attorney


Non-Attorney
Form HA-1 (XX-XX)

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
Collection and Use of Information from Your Appeal Form

5(c)
7(b)(3) or just 7(b)
Under section 7(b)(6) of the Railroad Retirement Act of 1974 and section 5(b) of the Railroad
Unemployment Insurance Act, the Railroad Retirement Board (RRB) is authorized to ask you for the
information on this form. You are not required to provide us with this information, however, if you do not
do so, we cannot process your appeal.
Although the information which we request is almost never used for any purpose other than the
processing of your appeal, the RRB does have the authority to release some or all of the following
information to the indicated individuals, organizations, and/or agencies without your approval:

d

1) Information may be release to an attorney, the Office of the President, a Congressional office, a
labor union, or to the Department of State’s embassy or consular offices if they allege to be
representing you at your request.
2) Information may be released to other people who are receiving benefits based on the same railroad
retirement account as you are, if the information affects their payments from the RRB.
3) Information may be released to a person who will receive benefits on your behalf, if the RRB
decides that some medical condition keeps you from receiving your own benefits.
4) Information (including medical records) may be released to people or organizations who are
working for the RRB.
5) Information may be released to your last employer to make sure that you are eligible to receive
benefits under the Railroad Retirement Act or under the Railroad Unemployment Insurance Act.
6) Information may be released in certain cases for law enforcement purposes and for court
proceedings.
A complete list of the persons, organizations or agencies to which the information you gave us may be
released is published in the Federal Register. The current list is available in any office of the RRB, if
you wish to see it.

We estimate this form takes an average of 20 minutes per response, including the time needed for
reviewing the instructions, getting the needed data, and reviewing the completed form. Federal agencies
may not conduct or sponsor, and respondents are not required to respond to, a collection of information
unless it displays a valid OMB number. If you wish, send comments regarding the accuracy of our
estimate or any other aspect of this form, including suggestions for reducing the completion time, to:
Associate Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 N.
Rush Street, Chicago, IL 60611-1275.

Form HA-1 (XX-XX)

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