Fill and Sign the Fillable Online Request for Hearing by Administrative Law Form

15. Check all claim types that apply: TO BE COMPLETED BY SOCI AL SECURITY ADMINISTR ATION- ACKNOWLEDGMENT OF REQUEST FOR HE ARING HO on Language (including sign language): 7. Do not complete if the appeal is a Medicare issue.Check one of the blocks: and I request that a decision be made based on the evidence in my case. (CompleteWaiverFormHA-4608) 14. Check one: 12. Claimant is represented 5. I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination made on my claim because: 6. I have additional evidence to submit. Name and address of source of additional evidence: 16. HO COPY SENT TO: 13. Inte rprete rneeded CF Attached: 11. Was the request fo rhea ringreceived within 65 da ysofthe reconside red dete rmination? REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE SOCIAL SECURITY ADMINISTRATION OFFICE OF DISABILIT YADJUDICATION AND REVIEW Form Approved OMB No. 0960-0269 If no is checked, attach claimant's explanation for delay; and attach copy of appointment notice, letter, or other pertinent material or informationin the Social Secu rityoffice. 17. CF COPY SENT TO: Form HA-501-U5 (5-2007) ef (5-2007) Destroy Prior Editions HO on (Cop yof email o rphone repo rt attached ) Other Attached: 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 t o complete this form, you should also print his or her name, address, etc., in No. 9. 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 no t done so previously, complete and submit form SSA-1696 (Appointment of Rep resentative) unless you a re appealing a Medica re issue. (Take or mail the signed originalto your local Social Security office, the Veterans Affairs Regional Office in Manila or any U.S. Foreign Service post and keep a copy for your records) (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.) (Title) (Address) (Servicing FO Code) (PC Code) Title II Disablility-worker or child only Title II Disability-Widow(er) only SSI Aged/Title II SSI Aged only SSI Blind only SSI Disability only SSI Blind/Title II Title XVIII Title VIII Only SSI Disability/Title II Yes No Yes No I do not wish to appear at a hearing I wish to appear at a hearing. Initial Entitlement Case Disability Cessation Case Other Postentitlement Case RSI onlySee Privacy Act Notice List of legal referral and service organizations provided Other - Specify: Title VIII/Title XVI Yes No 10. Request received for the Social Security Administration on by: (Date) (Print Name) ADDRESS 9. (REPRESENTATIVE'S SIGNATURE/NAME) 8. (CLAIMANT'S SIGNATURE) CITY STATE ZIP CODE - CITY STATE ZIP CODE - (DATE) TELEPHONE NUMBER ( ) - (DATE) TELEPHONE NUMBE R ( ) - FAX NUMBE R ( ) - FAX NUMBE R ( ) - ATTORNEY; NON ATTORNEY; (ADDRESS ) YES NO I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying stateme nts or forms, and it is true and correct to the best of my knowledge. An Administrative Law Judge of the Social Securit y Administration's Office of Disability Adjudication and Review or the Health and Human Services wil lbe appointed to conduct the hearing or other proceedings in your case. You will re ceive notice of the time and place of a hearing at least 20 days before the date set for a hearing. (RSI) (DIWC)(DIWW)(SSIA)(SSIB)(SSID)(SSAC)(SSBC)(SSDC)(HI/SMI)(SVB)(SVB/SSI) Title II; Title II; Title II; Title XVI; CF requested CF Attached: Title II CF held in FO Electronic Folder Title VIII; Title XVI; Title VIII; 2. WAGE EARNER NAME, IF DIFFERENT CLAIMANT SSN - - 1. CLAIMANT NAME SPOUSE'S CLAIM NUMBER OR SSN - - 3. CLAIMANT CLAIM NUMBER, IF DIFFERENT - - T XVIII TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS T XVIII Title XVI; T XVIII; 4. SPOUSE'S NAME, IF NOT WAGE EARNER FormHA-501-U5 (5-2007) ef (5-2007) PAPERWORK/PRIVACY ACT NOTICE The Social Security Act (sections 205(a) , 702, 1631(e)(1)(a) and (b), and 1869(b) (1) and (c), and Public Law 106-169 (Sect ion 809(a)(1) of Sections 251(a)) and Section 1839(i) of the Act (P.L. 108-173) as appropriate) authorizes the collection of information on this form. We need the information to continue processing your claim. You do not have to give it, but if you do not you may not receive benefits under the Social Security Act. We may give out the information on this form without your written consent if we need to get more information to decide if you are eligible for benefits or if a Federal law requires us to do so. Specifically, we may provide information to another Federal, State, or local government agency which is deciding your eligibility for a government benefit or program; to the President or a Congressman inquiring on your behalf; to an independent party who needs statistical information for a research paper or audit report on a Social Security program; or t o the Department of Justice to represent the Federal Government in a court suit rel ated to a program administered by the Social Security Administration. We expl ain, in the Federal Register, these and other reasons why we may use or give out information about you. If you would like more information, get in touch with any Social Security office, the Veterans Affairs Regional Office in Manila, or any U.S. Foreign Service post. We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Ma ny agencies may use matching programs to find or prove that a person qualifi es for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information about you may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office, the Veterans Affairs Regional Office in Manila, or any U.S. Foreign Service post. Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as am ended 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. 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.