Application of Circuit Court Law

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ON 03501-047 Sample Notice

EXHIBIT 2
Sample Notice
SOCIAL SECURITY ADMINISTRATION

READ CAREFULLY
The United States Court of Appeals for the (fill-in) Circuit has made a decision in
another case that could possibly affect the decision we made on your prior claim. The
name of the case is fill-in. In this case, the court found that (fill-in). We have issued the
(fill-in) acquiescence ruling, which is an instruction explaining how we will apply the
court decision to claims affected by the court's decision.
YOU MAY ASK US TO REVIEW YOUR EARLIER CLAlM
You should contact your local Social Security office if you would like us to make a new
decision on your claim based on the (fill-in) acquiescence ruling. If you contact us to
ask for a review of our earlier decision on your claim, you should provide us with the
name of the court case or the name of the Acquiescence Ruling (both noted above).
We will also ask you for any other information we need to help us decide whether
applying the acquiescence ruling to your claim could change our prior decision.
WHEN WE WILL MAKE A NEW DECISION ON YOUR PRIOR CLAIM
We will make a new decision on your prior claim only if, based on our review of the
information about your case, we determine that the (fill-in) acquiescence ruling could
change our prior decision.

LEGAL REPRESENTATlON
Ifyou have an attorney or someone else helping you with your claim, you should

contact him/her. You should also give him or her a copy of this notice.
1F YOU HAVE ANY QUESTIONS

If you have any questions,you may contact your local Social Security office. If you
call or visit a Social Security office, please have this letter with you. It will help us
answer your questiods). Also, if you plan to visit an office, you may call ahead to
make an appointment. This will help us serve you more quickly when you arrive at

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the office. We invite you to visit our web site at www.socialsecurit~.izovon t h e
Internet t o find general information about Social Security. If you have any specific
questions, you may call us toll-free at 1-800-772-1213,
or call your local office at
(fill-inlocal #). If you are deaf or hard of hearing, you may call our TTY number, 1800-325-0778. You can also write or visit any Social Security office.
S1 USTEDHABLA ESPANOL
Si usted habla espafiol y no entiende esta carta, por favor llame o visite su oficina
local de Seguro Social. Un representante de la oficina de Seguro Social le
explicari esta carta. Debe informarle que usted esti respondiendo al aviso, (Fill
in name of case).

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 control number. The OMB Number for this information
collection is 0960-0581. We estimate that it will take about 17 minutes to read the
instructions, gather the facts, and answer the questions. SEND OR BRING THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The
office is 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). You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.