Form SSA-525 Request to Decision Review Board to Vacate the Administr

Form Approved
OMB No. 0960-0755

Social Security Administration

REQUEST TO DECISIO REVIEW BOARD TO VACATE THE ADMIISTRATIVE LAW JUDGE
DISMISSAL OF HEARIG
(Take or mail the signed original to your local Social Security Office, the Veterans Affairs Regional Office in Manila
or any U.S. Foreign Service post. Please keep a copy for your records)

1. CLAIMANT

2. WAGE EARNER, IF DIFFERENT

3. SOCIAL SECURITY CLAIM NUMBER

4. SUPPLEMENTAL SECURITY INCOME (SSI) CLAIM
NUMBER

5. SPOUSE'S NAME (Complete ONLY in SSI cases)

6. SPOUSE'S SOCIAL SECURITY NUMBER
(Complete ONLY in SSI cases)

7. Type of Disability Claim:

Title II Disability

Supplemental Security Income

8. I request that the Decision Review Board review the Administrative Law Judge's dismissal action on the above claim because:

WRITTE STATEMET AD/OR ADDITIOAL EVIDECE
o You may submit a written statement to the Decision Review Board with this request for review. The written statement
may be no more than 2,000 words. If it is typed, it must be 12 point font or larger. The written statement should briefly
explain why you disagree with the Administrative Law Judge's action.
o You may submit evidence to show why you think the Administrative Law Judge should not have dismissed your request
for hearing. The Decision Review Board will accept only evidence that is relevant to the dismissal issue.
o Neither written statements nor additional evidence will be considered by the Decision Review Board if they are
submitted after you request review.
IMPORTAT: Write your Social Security Claim Number on any letter or material you send us.
SIGATURE BLOCKS: You should complete No. 9 and your representative (if any) should complete No. 10. 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.
10.
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.
9. CLAIMANT'S SIGNATURE

DATE

10. REPRESENTATIVE'S SIGNATURE

Attorney
Non-Attorney

PRINT NAME

PRINT NAME

ADDRESS

ADDRESS

(CITY, STATE, ZIP CODE)

(CITY, STATE, ZIP CODE)

PHONE NUMBER
(
)
Form SSA-525 (XX-2010)

FAX NUMBER
(
)

-

PHONE NUMBER
(
)
Page 1

FAX NUMBER
(
)

-

THE SOCIAL SECURITY ADMIISTRATIO STAFF WILL COMPLETE THIS PART
11. Request received for the Social Security Administration on _________________by:___________________________________
[Date]
[Print Name]

Title:

Address:

Servicing FO Code:

12. Is the request for review received within 65 days of the ALJ's Notice Denying Request to Vacate Dismissal?
Yes

13. If "No" checked:

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

PAPERWORK/PRIVACY ACT OTICE
The information requested on this form is authorized by the Social Security Act, sections 205(a) and
1631(e)(A) and (B) (42 U.S.C. § 405(a) and 1382(e) (A) and (B)), and Title 20 CFR 405.1, 405.380, 405.381,
405.383, and 405.427. The information provided will be used to begin a review by the Decision Review
Board of an Administrative Law Judge's dismissal of a request for hearing and refusal to vacate that dismissal
action. Your response to the questions on this form is voluntary; however, the Social Security Administration
(SSA) cannot review the dismissal action on your claim unless the information is furnished. While the
information you furnish on this form would almost never be used for any purpose other than making a
determination on the propriety of the dismissal action, such information may be disclosed by SSA as generally
permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using the
information as necessary for administrativePlease
purposes
or as
authorized by routine uses in the applicable Privacy
see
revised
Act system of records. For example, SSA may
disclose
information
to other agencies such as the Government
Privacy Act
Accountability Office or to the DepartmentStatement
of Veteransbelow.
Affairs to comply with Federal Laws requiring the
release of information from our records. SSA may also use the information you give us when we match
records by computer. Matched programs compare SSA records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove that a person qualifies for
benefits paid by the Federal government. The law allows SSA to do this even if you do not agree to it.
Explanations about possible reasons why information you provide us may be used or given out are available
upon request from any Social Security office.
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. We estimate that it
will take about 30 minutes to read the instructions, gather the facts, and answer the questions. SED OR
BRIG 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.

Form SSA-525 (XX-2010)

Page 2

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1631(e)(A) and (B) (42 U.S.C. § 405(a) and 1382(e) (A) and (B)) of the
Social Security Act, as amended, and Title 20 CFR 405.1, 405.380, 405.381, 405.383, and
405.427, authorize us to collect this information. The information you provide will be used to
begin a review by the Decision Review Board of an Administrative Law Judge’s dismissal of a
request for hearing and refusal to vacate that dismissal action.
The information you furnish on this form is voluntary. However, failure to provide this
requested information could prevent the Social Security Administration from reviewing the
dismissal action on your claim.
We rarely use the information you supply for any purpose other than for making a determination
on the propriety of the dismissal action. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not limited to
the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for Federally-funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records
Notices entitled, Administrative Law Judge Working File on Claimant Cases, 60-0005. These
notices, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.