Fill and Sign the Spouses Name and Social Security Number Form

TELEPHONE NUMBER ( ) - THE SOCIAL SECURITY ADMINISTRATION STAFF WILL COMPLETE THIS PART 4. SPOUSE'S NAME AND SOCIAL SECURITY NUMBER(Complete ONLY in Supplemental Security Income Case) 5. I request that the Appeals Council review the Administrative Law Judge's action on the above claim because : 9. Is the request for review received within 65 days of the ALJ's Decision/Dismissal? REQUEST FOR REVIEW OF HEARING DECISION/ORDER 1. CLAIMANT Form HA-520-U5 (5-2003) ef (05-2005) Dest royPriorEditions 12. Check all claim t ypes that a pply: SOCIAL SECURITY ADMINISTRATION /OFFICE OF HEARINGS AND APPEALS Form Approved OMB No. 0960-0277 See Privacy Act Notice 3. SOCIAL SECURITY CLAIM NUMBE R - - 2. WAGE EARNER, IF DIFFERENT APPEALS COUNCIL OFFICE OF HEARINGS AND APPEALS, SSA 5107 Leesburg Pike FALLS CHURCH, VA 22041 - 3255 SIGNATURE BLOCKS: You should complete No. 6 and your represent ative (if any) should complete No. 7. 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. 7. 11. Check one: 10. If "No" checked: (1) attach claimant's explanation for delay; and (2) attach copy of appointment notice, letter or other pertinent material or inform ation in the Social Security Office. (Title)(Address) (Servicing FO Code) (PC Code) 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. If you request an extension of t ime, 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 Claim Number on any letter or material you send us. Retirement or survivors Disability-Worker Disability-Widow(er) Disability-Child SSI Aged SSI Blind SSI Disability Health Insurance-Part A Health Insurance-Part B Other - Specify: (Do not use this form for objecting to a recommended ALJ decision.) (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) Title VIII Only Title VIII/Title XVI Initial Entitlement Termination or other Yes No (RSI) (DIWE)(DIWW)(DIWC)(SSIA)(SSIB)(SSID)(HIA)(HIB)(SVB)(SVB/SSI) TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying st atements or forms, and it is true and correct to the best of my knowledge. 8. Request received for the Social Security Administration on by: (Date)(Print Name) (CITY, STATE, ZIP CODE) FAX NUMBER ( ) - ADDRESS PRINT NAME ADDRESS PRINT NAME (CITY, STATE, ZIP CODE) FAX NUMBER ( ) - TELEPHONE NUMBER ( ) - 7. REPRESENTATIVE'S SIGNATURE 6. CLAIMANT'S SIGNATURE DATE ATTORNEY NON-ATTORNEY 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)) 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 u nder 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 e ligible for benefits or if a Federal law requires us to do so. Specifically, we mayprovideinformationtoanother Federal, State, or local government agency which is deciding your eligibility for a government benefit or program; to the Pr esident 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 to the Department of Justice to represent the Federal Gove rnment in a court suit related to a program administered by the Social Security Admi nistration. We explain, 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 Regiona l 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 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 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 at1-800-772-1213. You may send comments on our time estimate above to :SSA , 1338 Annex Building, Ba ltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form. Form HA-520-U5 (5-2003) ef (05-2005)