Request for Hearing By Administrative Law Judge--Paper/MCS/MSSICS Versions

RECONSIDERATION REQUEST 1/ FEDRO
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C M C S R E CON S I DE R ATI O N R E QUE S T (R C N1)
OR FE D R O (FD R 1 )S D 3
0
N H S S SSS S S SS
S S S SS SS S S SS S SSS
C L SS S S SS S SS
SS S SS S SS S SSS S S S
L
U
C RO S S R E F ER E NCE
S SN: S SS S SSS S S
BIC: SS
SS N : S S S SS S SSS
BI C : S S
M
A PP E LLA N T ( I F O T H ER THA N CL M T O R RE P ): X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XX
N
A DD R ESS : XX X XXX X X XX X XXX X X XX X XXX
XX X XXX X X XX X XXX X X XX X XXX
*
XX X XXX X X XX X XXX X X XX X XXX
XX X XXX X X XX X XXX X X XX X XXX
O
C ITY : XX X XXX X X XX X XXX X X XX
S T AT E : X X
ZIP : 99 9 99
PH O NE: 9 99 999 9 99 9
N
C OU N TRY : XX X XXX X X XX X XXX X
CON S U L C ODE : 99 9
E
B IC : XX
S POU S E S S N: 9 9 99 9 999 9
CAS E TY P E: 9 1. INI T I AL ENT
E XP L ANA T I ON PRO V I DE D (Y / N ): X
RE Q UES T E D ( Y/N ) : X

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A PP E AL C L AI M TY P E : 9 9
1 . R SI
RSI
5 . SS I BL I N D/ T ITL E II
SS B C
2 . D ISA B I LI T Y W O R KE R OR C HI L D D I WC
6 . SS I DI S A BI L ITY / T IT L E I I SS D C
3 . D ISA B I LI T Y W I D OW ( ER)
D I WW
7 . HE A LTH I NS ENT
HI E
4 . S SI A G ED / TIT L E I I
S S AC
8 . OT H ER X X XX X XXX X X XX X XXX X X XX X XX
I SS U E: X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XX
R EA S ON R E QU E STE D : X X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XX
X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
A DD I TIO N A L E VID E N CE (Y/ N / F) : X
* * * ** * *** * * ** * (LI N E 2 3 RE S E RV E D F O R A P PLI C A TI O NS I N FO R MAT I O N) * *** * * ** * *** * * ** *
* * * ** * *** * * ** * (LI N E 2 4 RE S E RV E D F O R O P ERA T I NG SYS T E MS INF O R MA T ION ) * ** * *** * * **
*THE TITLE OF THIS SCREEN WILL CHANGE BASED ON THE SELECTION MADE ON THE
NAPP (APPEALS ESTABLISHMENT SCREEN)

The key to the highlight values is:
Yellow Mandatory
Green Conditional
Blue
Optional

8
0
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0
1
C
0
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R
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S
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R
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D

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234567890123456789012345678901234567890123456789012345678901234567890123456789
MCS
RECONSIDERATION REQUEST 2 OR FEDRO 2
SD3
NH SSSSSSSSS
SSSSS SSSSSSSSSS
CL SSSSSSSSS
SSSSS SSSSSSSSSS
SSI APPEAL: 9

1. CASE REVIEW

2. INFORMAL CONFERENCE

3. FORMAL CONFERENCE

IF CLAIMANT REQUESTS OPTION 2 OR 3 UNDER SSI RECON, IS INTERPRETER
NEEDED (Y/N): X
IF YES, SPECIFY LANGUAGE: XXXXXXXXXXXXXXXXXXXXXX
REPRESENTED (Y/N): X
IF NO, LEGAL REFERRAL LIST TO CL (Y/N): X
ATTORNEY/REP NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
IF YES, ATTY (Y/N): X
ATTORNEY/REP ADDRESS: XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX
CITY: XXXXXXXXXXXXXXXXXX
STATE: XX
ZIP: 99999
PHONE: 999 999 9999
COUNTRY: XXXXXXXXXXXXXXX
CONSUL CODE: 999
FILED BY: 9
1. APPELLANT
2. REP
DATE FILED: 999999
DETER DATE BEING APPEALED: 999999
TIMELY REQUEST (Y/N): X
IF NO,: 9
1. CLMT’S EXPLANATION
2. OTHER INFORMATION 3. BOTH 1 AND 2 APPLY
EXPLANATION:XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
DATE SCREEN BEGUN: 999999
**************(LINE 23 RESERVED FOR APPLICATIONS INFORMATION)*****************
**************(LINE 24 RESERVED FOR OPERATING SYSTEMS INFORMATION)***********

The key to the highlight values is:
Yellow Mandatory
Green Conditional
Blue
Optional

8
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1 2 3 4 56 7 890 1 2 34 5 678 9 0 12 3 456 7 8 90 1 234 5 6 78 9 012 3 4 56 7 890 1 2 34 5 678 9 0 12 3 456 7 8 90 1 234 5 6 78 9
C MCS
H EAR I N G R EQU E S T 1
HNG 1 SD 3
0
NH SSS S S SS S S
SS S SS S S SS S SSS S S
CL S SS S SSS S S
SSS S S S S SSS S S SS S
L
U
C R OS S RE F E RE N CE
S S N: S S SS S SSS S
BI C : S S
SS N : S S S SS S SSS
BIC : SS
M
A P PE L LAN T (I F OT H E R T HAN C LM T OR R EP ) : X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
N
A D DR E SS: X XX X XXX X X XX X XXX X X XX X XX X XX X XXX X X XX X XXX X X XX X XX
*
X XX X XXX X X XX X XXX X X XX X XX X XX X XXX X X XX X XXX X X XX X XX
O
C I TY: X XX X XXX X X XX X XXX X X X
S T A TE : XX
Z IP: 9 99 9 9
PH O NE: 9 99 999 9 99 9
N
C O UN T RY: X XX X XXX X X XX X XXX
C ONS U L C O DE: 9 99
E
B I C: XX
S POU S E S S N: 9 9 99 9 999 9
CAS E TY P E: 9 1. INI T I AL ENT
A P PE A L C L A IM TYP E : 9 9
R
1. RSI
RSI
5. S S I B LIN D / TI T LE I I
S SB C
E
2 . D I SAB I L IT Y WO R K ER OR C H IL D D I W C 6. S S I D ISA B I LI T Y/T I T LE II S SD C
S
3 . D I SAB I L IT Y WI D O W( E R)
D I W W 7. H E AL T H I N S E N T
H IE
E
4 . S S I A G E D/ T ITL E II
S S A C 8. O T HE R
R
H E AR I NG R E QU E STE D (Y / N): X
V
R E AS O N H E A RI N G R E Q UE S TED : XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
E
X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
D
X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
A D DI T ION A L E V IDE N C E ( Y/N / F ): X
* * * ** * *** * * ** * (LI N E 2 3 RE S E RV E D F O R A P PLI C A TI O NS I N FO R MAT I O N) * *** * * ** * *** * * ** *
* * * ** * *** * * ** * (LI N E 2 4 RE S E RV E D F O R O P ERA T I NG SYS T E MS INF O R MA T ION ) * ** * *** * * **

The key to the highlight values is:
Yellow Mandatory
Green Conditional
Blue
Optional

8
0
6

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0
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O
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E
R
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S
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R
V
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D

1
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2 3 4 56 7 890 1 2 34 5 678 9 0 12 3 456 7 8 90 1 234 5 6 78 9 012 3 4 56 7 890 1 2 34 5 678 9 0 12 3 456 7 8 90 1 234 5 6 78 9
MCS
H E A RI N G R E Q UE S T 2
HNG 2 SD 3
NH SSS S S SS S S
S SSS S S SS S SSS S S SS
C L S SSS S S SS S
S SS S SSS S S SS S SSS S
R E Q UE S T O R A L H EAR I N G ( Y/N ) : X
R E AS O N H E A RI N G W A I VE D : X X X XX X XXX X X XX X XXX X X X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
R E P RE S ENT E D ( Y /N) : X
I F NO , LE G A L R EFE R R AL LIS T TO CLM T (Y / N): X
A T T OR N EY/ R E P N AME : XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX
I F YE S , A T TY ( Y /N ) :
A T T OR N EY/ R E P A DDR E S S: XXX X X XX X XXX X X XX X XXX X X X
X X XX X XXX X X XX X XXX X X XX X X
XXX X X XX X XXX X X XX X XXX X X X
X X XX X XXX X X XX X XXX X X XX X X
C I T Y: XXX X X XX X XXX X X XX X XX
S T ATE : XX
Z I P: 999 9 9
PH O N E: 999 9 99 999 9
C O U NT R Y: X X XX X XXX X X XX X XX
C O NSU L CO D E: 9 9 9
F I L ED BY: 9 1 . A P P EL L ANT
2 . RE P
D ATE F IL E D: 9 9 99 9 9
D E T ER DAT E BE I NG A P PE A LED : 99 9 999
T IME L Y R E QUE S T ( Y /N) : X
I F NO , : 9
1 . CL M T ’S EXP L A NA T ION
2. OTH E R I N FOR M A TI O N 3 . B O TH 1 AN D 2 A P PL Y
E X P LA N ATI O N : X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
X X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X XXX X X XX X
I N T ER P RET E R ( Y /N) : X
I F YE S , S P E CI F Y L A N GU A GE: X XX X XXX X X XX X XXX X X XX X XX
* * * ** * *** * * ** * (LI N E 2 3 RE S E RV E D F O R A P PLI C A TI O NS I N FO R MAT I O N) * *** * * ** * *** * * ** *
* * * ** * *** * * ** * (LI N E 2 4 RE S E RV E D F O R O P ERA T I NG SYS T E MS INF O R MA T ION ) * ** * *** * * **

The key to the highlight values is:
Yellow Mandatory
Green Conditional
Blue
Optional

8
0
7

MCS
NH: SSSSSSSSS
DISPOSITION: 9

APPEAL DISPOSITION
SSSSS SSSSSSSSSS
CL: SSSSSSSSS
1. UNFAVORABLE DENIAL
2. PARTIALLY FAVORABLE ALLOW
3. FULLY FAVORABLE ALLOW

DISPOSITION DATE: 999999

DISP SD38
SSSSS SSSSSSSSSS

4. DISMISSAL
5. WITHDRAWAL
6. REMAND

7. ABANDON

EFFECTUATION DATE: 999999

ALJ: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

ALJ HO: XXXX

********************************************************************************
********************************************************************************
The key
Yellow
Green
Blue

to the highlight values is:
Mandatory
Conditional
Optional

MCS
APPEAL ESTABLISHMENT
NH NAME: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS
NH SSN: SSSSSSSSS
APPEAL
LEV: I
R
H
O
F

NAPP SM20

FILE LEVEL: 9
1. RECON 2. HEARING
3. FEDRO REVIEW
INITIAL
DECISION STATUS:
RECON
1 RSHI ALLOW
5 DIB MED DENY
9 RSHI PARTIAL
HEARING
2 RSHI DISAL
6 NON-MED COMP
10 DIB PARTIAL
REOPEN
3 DIB TECH DIS
7 WITH/ABATE
11 DISMISSAL
FEDRO
4 DIB ALLOW
8 DELAY
FILE
ADJ
CL NAME
CL SSN
DATE
DEC DATE LEV SELECT
01. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
02. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
03. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
04. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
05. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
06. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
07. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
08. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
09. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
10. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
11. SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSSSSSSSS SSSSSS SS SSSSSS S
X
********************************************************************************
********************************************************************************

The key
Yellow
Green
Blue
Note:

to the highlight values is:
Mandatory
Conditional
Optional
APPEAL FILE LEVEL is prefilled in update mode
SELECT is not an MCS Data element on the MCS pending file

Iappeals final mapping document

MCS
Screen MCS Screen Name
ID

NAPP

RCN1
OR
FDR1

RCN2
OR
FDR2

APPEAL
ESTABLISHMENT

MCS Data Element

MCS Screen Questions
(Conditional )
(Mandatory)

Edits
(1) MUST BE A 1, 2, OR 3
(SURFACE)
(2) NO ENTRY CAN BE MADE IF
DEC IS BLANK (RELATIONAL)
DATA MUST BE AN X
(SURFACE)

D1XO-CC-SEG-APPEAL-LEVEL-F1

APPEAL FILE LEVEL

N/A

SELECT

D1XO-PC-RC-BIC-F1

BIC

(1) CHARACTERS OTHER THAN
ALPHA/NUMERIC (SURFACE)
(2) VALID BIC (SURFACE)

D1XO-PC-RC-CASE-TYPE-F1
D1XO-PC-RC-EXPL-PROV-F1

CASE TYPE
EXPLANATION PROVIDED (Y/N)

NONE
DATA NOT Y OR N (SURFACE)

RECONSIDERATION D1XO-PC-RC-RECN-REQ-F1
REQUEST 1
D1XO-PC-RC-CLM-TYPE
OR
FEDRO REVIEW

RECON/FEDRO REQUESTED (Y/N) DATA NOT Y OR N (SURFACE)
APPEAL CLAIM TYPE

DATA OTHER THAN 1-8
(SUFACE)

D1XO-PC-RC-CLM-EXPL-F1

OTHER

IF APPEAL CLAIM TYPE = 8,
FIELD NEEDS DATA
(RELATIONAL)

D1XO-PC-RC-RECN-ISS-F1
D1XO-PC-RC-REA-RECN-RQD1-F1
D1XO-PC-RC-REA-RECN-RQD2-F1

ISSUE

NONE

REASON REQUESTED

NONE

D1XO-PC-RC-ADL-EVID-F1

ADDITIONAL EVIDENCE (Y/N/F)

DATA OTHER THAN Y, N, OR F
(SURFACE)

REPRESENTED (Y/N)

DATA NOT Y OR N (SURFACE)

RECONSIDERATION D1XO-PC-RC2-REP-F1
REQUEST 2
D1XO-PC-RC2-LEG-REF-LIST-F1
OR
FEDRO REVIEW

D1XO-PC-RC2-ATTY-NM-F1

IF NO, LEGAL REFERRAL LIST TO
DATA NOT Y OR N (SURFACE)
CL (Y/N)
MANDATORY FIELD IF
REPRESENTED IS ANSWERED
ATTORNEY/REP NAME
YES

Page 1 of 6

Iappeals final mapping document

D1XO-PC-RC2-ATTY-F1

IF YES, ATTY (Y/N)

Page 2 of 6

(1) DATA NOT Y OR N
(SURFACE)
(2) ATTY DATA ELEMENT MUST
BE ANSWERED IF APPELLANT
REPRESENTED IS ANSWERED
YES (RELATIONAL)
(3) ATTY CANNOT BE
ANSWERED IF REPRESENTED
IS ANSWERED NO
(RELATIONAL)

Iappeals final mapping document

D1XO-PC-RC2-ATTY-ADDR-LN-F1
D1XO-PC-RC2-ATTY-CITY

ATTORNEY/REP ADDRESS
CITY

D1X0-PC-RC2-ATTY-STATE-F1

STATE

D1XO-PC-REC2-ATTY-ZIP-F1

ZIP

D1XO-PC-RC2-RECN-FILED-BY-F1

FILED BY
DATE FILED

D1XO-PC-RC2-RECN-FL-DT-D3

HNG1

HEARING REQUEST 1

D1XO-PC-RC2-DETER-DT-D3
D1XO-PC-RC2-TMLY-REQ-F1

DETER DATE BEING APPEALED
TIMELY REQUEST (Y/N)

D1XO-PC-RC2-NT-TMLY-REAS-F1

IF NO

D1XO-PC-RC2-NT-TMLY-EXP-F1
D1XO-PC-RC2-NT-TMLY-EXP2-F1

EXPLANATION:

MANDATORY FIELD IF
REPRESENTED IS ANSWERED
YES (RELATIONAL)
MANDATORY FIELD IF
REPRESENTED IS ANSWERED
YES (RELATIONAL)
(1) DATE IS NOT A VALID
STATE (SURFACE)
(2) MANDATORY FIELD IF
REPRESENTED IS ANSWERED
YES (RELATIONAL)
(1) DATE IS NOT A VALID ZIP
CODE (SURFACE)
(2) MANDATORY FIELD IF
REPRESENTED IS ANSWERED
YES (RELATIONAL)

DATA OTHER THAN 1 OR 2
(1) CANNOT BE A FUTURE
DATE (SURFACE)
(2) MUST BE A VALID DATE
(SURFACE)
(1) CANNOT BE A FUTURE
DATE (SURFACE)
(2) MUST BE A VALID DATE
(SURFACE)
DATA NOT Y OR N (SURFACE)

(1) DATA MUST BE 1, 2, OR 3
(SURFACE)
(2) MANDATORY FIELD IF
TIMELY REQUEST IS
ANSWERED NO (RELATIONAL)
MANDATORY FIELD IF TIMELY
REQUEST IS ANSWERED NO
(RELATIONAL)

D1XO-PC-RC2-SCR-BGN-DT-MDY

DATE SCREEN BEGUN

(1) MUST BE A VALID DATE
(SURFACE)
(2) DATE LATER THAN A
CURRENT DATE (SURFACE)

D1XO-PC-HG-APPEAL-ADDR-LN-F1

ADDR

DATA OTHER THAN A-Z, 0-9,
OR HYPHEN (SURFACE)

Page 3 of 6

Iappeals final mapping document

CITY

D1XO-PC-HG-APPEAL-STATE-F1

STATE

D1XO-PC-HG-APPEAL-ZIP-F1

ZIP

D1XO-PC-HG-CASE-TYPE-F1

CASE TYPE

D1XO-PC-HG-BIC-F1

BIC

(1) CHARACTERS OTHER THAN
ALPHA/NUMERIC (SURFACE)
(2) VALID BIC (SURFACE)

APPEAL CLAIM TYPE

DATA OTHER THAN 1-8
(SUFACE)

D1XO-PC-HG-CLM-TYPE

D1XO-PC-HG-CLM-EXPL-F1

OTHER

IF APPEAL CLAIM TYPE = 8,
FIELD NEEDS DATA
(RELATIONAL)

D1XO-PC-HG-HEAR-RQSTD-F1
D1XO-PC-HG-REAS-HR-RQD1-F1
D1XO-PC-HG-REAS-HR-RQD2-F1

HEARING REQUESTED (Y/N)

DATA NOT Y OR N (SURFACE)

REASON HEARING REQUESTED

NONE

ADDITIONAL EVIDENCE (Y/N/F)

DATA NOT Y, N, OR F
(SURFACE)

D1XO-PC-HG2-RQST-ORAL-HEAR-F1

REQUEST ORAL HEARING (Y/N)

DATA NOT Y OR N (SURFACE)

D1XO-PC-HG2-REAS-HEAR-WV1-F1
D1XO-PC-HG2-REAS-HEAR-WV2-F1

REASON HEARING WAIVED:

MUST BE COMPLETED IF
REQUESTED ORAL HEARING IS
ANSWERED NO (RELATIONAL)

D1XO-PC-HG2-REP-F1

REPRESENTED (Y/N)

DATA NOT Y OR N (SURFACE)

D1XO-PC-HG-ADL-EVID-F1
HNG2

HEARING REQUEST 2

MUST CONTAIN DATA IF
ADDRESS CONTAINS DATA
(RELATIONAL)
(1) DATE IS NOT A VALID
STATE (SURFACE)
(2) STATE ELEMENT AND ZIP
ELEMENT CONFLICTING
(RELATIONAL)
(3) STATE ENTRY INVALID IF
COUNTRY OR CONSUL CODE
PRESENT (RELATIONAL)
(1) DATE IS NOT A VALID ZIP
CODE (SURFACE)
(2) MANDATORY FIELD IF
REPRESENTED IS ANSWERED
YES (RELATIONAL)
NONE

D1XO-PC-HG-APPEAL-CITY-F1

Page 4 of 6

Iappeals final mapping document

D1XO-PC-HG2-LEG-REF-LIST-F1

D1XO-PC-HG2-ATTY-NM-F1

D1XO-PC-HG2-ATTY-F1

D1XO-PC-HG2-ATTY-ADDR-LN-F1
D1XO-PC-HG2-ATTY-CITY-F1

D1XO-PC-HG2-ATTY-STATE-F1

D1XO-PC-HG2-ATTY-ZIP-F1

(1) DATA NOT Y OR N
(SURFACE)
IF NO, LEGAL REFERRAL LIST TO
(2) MUST BE COMPLETED IF
CLMT (Y/N):
REPRESENTED IS ANSWERED
NO (RELATIONAL)
MANDATORY FIELD IF
REPRESENTED IS ANSWERED
ATTORNEY/REP NAME:
YES (RELATIONAL)
(1) DATA MUST BE A Y OR N
(SURFACE)
(2) MANDATORY FIELD IF
IF YES, ATTY (Y/N):
REPRESENTED IS ANSWERED
YES (RELATIONAL)
MANDATORY FIELD IF
REPRESENTED IS ANSWERED
ATTORNEY/REP ADDRESS
YES (RELATIONAL)
MANDATORY FIELD IF
REPRESENTED IS ANSWERED
CITY
YES (RELATIONAL)
(1) DATE IS NOT A VALID
STATE (SURFACE)
(2) STATE AND ZIP MUST NOT
CONFLICT
STATE
(3) MANDATORY FIELD IF
REPRESENTED IS ANSWERED
YES (RELATIONAL)
(1) DATE IS NOT A VALID ZIP
CODE (SURFACE)
ZIP
(2) MANDATORY FIELD IF
REPRESENTED IS ANSWERED
YES (RELATIONAL)

D1XO-PC-HG2-RECON-FILED-BY-F1

FILED BY

D1XO-PC-HG2-RECN-FL-DT-D3

DATE FILED

D1XO-PC-HG2-DETER-DT-D3

DETER DATE BEING APPEALED

D1XO-PC-HG2-TMLY-REQ-F1

TIMELY REQUEST (Y/N)

Page 5 of 6

DATA NOT 1 OR 2 (SURFACE)
(1) CANNOT BE A FUTURE
DATE (SURFACE)
(2) MUST BE A VALID DATE
(SURFACE)
(1) CANNOT BE A FUTURE
DATE (SURFACE)
(2) MUST BE A VALID DATE
(SURFACE)
DATA MUST BE A Y OR N
(SURFACE)

Iappeals final mapping document

DISP

D1XO-PC-HG2-TMLY-REAS-F1

IF NO

D1XO-PC-HG2-NT-TMLY-EXP-F1
D1XO-PC-HG2-NT-TMLY-EXP2-F1

EXPLANATION:

D1XO-PC-HG2-INTER-F1

INTERPRETER (Y/N)

D1XO-PC-HG2-LANG-F1

IF YES, SPECIFY LANGUAGE

APPEAL DISPOSITION D1XO-PC-AP-DISPOS-F1
D1XO-PC-DISPOS-DT-D3

DISPOSITION
DISPOSITION DATE

Page 6 of 6

(1) DATA MUST BE A 1, 2, OR 3
(SURFACE)
(2) MANDATORY IF TIMELY
REQUEST IS ANSWERED NO
(RELATIONAL)
MUST BE COMPLETED IF
REQUEST TIMELY IS
ANSWERED NO (RELATIONAL)
DATA IS NOT Y OR N
(SURFACE)

NONE

DATA MUST BE 1-7 (SURFACE)
(1) CANNOT BE A FUTURE
DATE (SURFACE)
(2) MUST BE A VALID DATE
(SURFACE)