Omb 0960 0277 Form

Form Approved OMB No. 0960-0277 SOCIAL SECURITY ADMINISTRATION/OFFICE OF DISABILITY ADJUDICATION AND REVIEW REQUEST FOR REVIEW OF HEARING DECISION/ORDER Do not use this form for objecting to a recommended ALJ decision. Either mail the signed original form to the Appeals Council at the address shown below or take or mail the signed original to your local Social Security office the Department of Veterans Affairs Regional 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 See Privacy Act Notice 3. CLAIMANT CLAIM NUMBER IF DIFFERENT - 4. I request that the Appeals Council review the Administrative Law Judge s action on the above claim because ADDITIONAL EVIDENCE If you have additional evidence submit it with this request for review. If you need additional time to submit evidence or legal argument you must request an extension of time in writing now. This will ensure that the Appeals Council has the opportunity to consider the additional evidence before taking its action* If you request an extension of time you should explain the reason s you are unable to submit the evidence or legal argument now. If you neither submit evidence or legal argument now nor within any extension of time the Appeals Council grants the Appeals Council will take its action based on the evidence of record. IMPORTANT WRITE YOUR SOCIAL SECURITY NUMBER ON ANY LETTER OR MATERIAL YOU SEND US* IF YOU RECEIVED A BARCODE FROM US THE BARCODE SHOULD ACCOMPANY THIS DOCUMENT AND ANY OTHER MATERIAL YOU SUBMIT TO US* SIGNATURE BLOCKS You should complete No* 5 and your representative if any should complete No* 6. 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* 6. 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. DATE 6. REPRESENTATIVE S SIGNATURE NON-ATTORNEY ATTORNEY PRINT NAME ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER FAX NUMBER THE SOCIAL SECURITY ADMINISTRATION STAFF WILL COMPLETE THIS PART by 7. Request received for the Social Security Administration on Date Title Print Name Address Servicing FO Code 8. Is the request for review received within 65 days of the ALJ s Decision/Dismissal 9. If No checked 10. Check one Yes PC Code 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. 11. Check all claim types that apply Initial Entitlement Termination or other APPEALS COUNCIL OFFICE OF DISABILITY ADJUDICATION AND REVIEW SSA 5107 Leesburg Pike FALLS CHURCH VA 22041 - 3255 Form HA-520-U5 07-2011 ef 07-2011 Destroy Prior Editions Retirement or survivors Disability-Worker Disability-Child SSI Aged SSI Blind SSI Disability Title VIII Only Title VIII/Title XVI Other - Specify RSI DIWC DIWW SSIA SSIB SSID SVB SVB/SSI TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS Privacy Act Statement Request for Review of Hearing Decision/Order Sections 205 a 702 1631 e 1 a and b and 1869 b 1 and c of the Social Security Act and Public Law 106-169 sections 809 a 1 and 251 a as amended authorize us to collect this information* The information you provide on this form is used to complete our claims process.