Current HA-501

SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW

Form Approved
OMB No. 0960-0269

REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE

See

(Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional Privacy Act Notice
Office in Manila or any U.S. Foreign Service post and keep a copy for your records)
1. CLAIMANT NAME

CLAIMANT SSN

2. WAGE EARNER NAME, IF DIFFERENT

3. CLAIMANT CLAIM NUMBER, IF DIFFERENT

4. SPOUSE'S NAME, IF NOT WAGE EARNER

SPOUSE'S CLAIM NUMBER OR SSN

5. I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination made on my claim because:

An Administrative Law Judge of the Social Security Administration's Office of Disability Adjudication and Review or the Health and Human Services will be
appointed to conduct the hearing or other proceedings in your case. You will receive notice of the time and place of a hearing at least 20 days before the
date set for a hearing.
6. I have additional evidence to submit.

7. Do not complete if the appeal is a Medicare
issue.
Check one of the blocks:

No

Yes

Name and address of source of additional evidence:

I wish to appear at a hearing.
I do not wish to appear at a hearing
and I request that a decision be made
based on the evidence in my case.
(Complete Waiver Form HA-4608)

(Please submit it to the hearing office within 10 days. Your servicing Social Security Office will
provide the address. Attach an additional sheet if you need more space.)

You have a right to be represented at the hearing. If you are not represented but would like to be, your Social Security office will give you a list of
legal referral and service organizations. If you are represented and have not done so previously, complete and submit form SSA-1696
(Appointment of Representative) unless you are appealing a Medicare issue.
Regardless of the issue you are appealing, you should complete No. 8 and your representative (if any) should complete No. 9. 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. 9.

DATE

8. CLAIMANT'S SIGNATURE- Optional
RESIDENCE ADDRESS

ATTORNEY

ADDRESS

STATE

CITY

TELEPHONE NUMBER

DATE

9. REPRESENTATIVE'S NAME

ZIP CODE

STATE

CITY

FAX NUMBER

NON-ATTORNEY

TELEPHONE NUMBER

ZIP CODE

FAX NUMBER

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION- ACKNOWLEDGMENT OF REQUEST FOR HEARING
10. Request received for the Social Security Administration on

by:

(Print Name)

(Date)
(Title)

(Address)

(Servicing FO Code)

(PC Code)

11. Was the request for hearing received within 65 days of the reconsidered determination?
YES
NO
If no is checked, attach claimant's explanation for delay; and attach copy of appointment notice, letter, or other pertinent material or information in the
Social Security office.
12. Claimant is represented
15. Check all claim types that apply:
Yes
No
List of legal referral and service organizations provided
(RSI)
RSI only
13. Interpreter needed
Yes
No
(DIWC)
Title II Disability-worker or child only
Language (including sign language):
(DIWW)
Title II Disability-Widow(er) only
14. Check one:
Initial Entitlement Case
(SSIA)
SSI Aged only
Disability Cessation Case
(SSIB)
SSI Blind only
Other Postentitlement Case
(SSID)
SSI Disability only
HO on
16. HO COPY SENT TO:
(SSAC)
SSI Aged/Title II
T XVIII;
CF Attached:
Title II;
Title XVI;
Title VIII;
(SSBC)
SSI Blind/Title II
Title II CF held in FO
Electronic Folder
(SSDC)
SSI Disability/Title II
CF requested
Title II;
Title VIII;
T XVIII
Title XVI;
(Copy of email or phone report attached )
17. CF COPY SENT TO:
CF Attached:
Other Attached:

Title XVIII

HO on
Title II;

Title XVI;

Title XVIII

(HI/SMI)

Title VIII Only

(SVB)

Title VIII/Title XVI

(SVB/SSI)

Other - Specify:

Form HA-501-U5 (08-2012) ef (08-2012)
TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS
Use 02-2011 Edition Until Stock is Exhausted

PRIVACY ACT STATEMENT

Request for Hearing by Administrative Law Judge
Sections 205(a) (42 U.S.C. 405 (a)), 702 (42 U.S.C. 902), 1631(e) (1) (A), and; (B) (42 U.S.C. 1383(e) (1) (A) and (B)),
1839(i) (42 U.S.C. 1395r), 1869(b) (1), and (c) (42 U.S.C. 1395ff) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to continue processing your claim.
Providing this information is voluntary. However, failing to provide us with all or part of the requested information may
prevent us from making an accurate and timely decision on your claim.
We rarely use the information you supply for any purpose other than for determining problems in Social Security
programs. 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 Medicare 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 the 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 investigate activities necessary to assure the integrity of Social
Security programs.
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 System of Records Notices 60-0089, Claims Folder
System and 60-0050, Completed Determination-Continuing Disablility Determinations. These notices, additional
information regarding this form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or any local 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 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). 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 HA-501-U5 (08-2012) ef (08-2012)