Fill and Sign the Information on This Form is Authorized by Regulation 20 Cfr 404

3. IS THIS REQUEST FILED TIMELY? (If "NO", attach claimant's explanation for delay and attach only pertinent letter, material, or information in social security office.) YES NO DISABILITY DETERMINATION SERVICES (ROUTE WITH ODO, BALTIMORE PROGRAM SERVICE CENTER DISABILITY FOLDER) INTPSC, BALTIMORE OCRO BALTIMORE NO FURTHER DEVELOPMENT REQUIRED (GN 03102.125) REQUIRED DEVELOPMENT ATTACHEDREQUIRED DEVELOPMENT PENDING, WILL FORWARD OR ADVISE STATUS WITHIN 30 DAYS YES NO 2. CLAIMANT INSISTS ON FILING YES NO Case Review Informal Conference Formal Conference DEPARTMENT OF HEALTH AND HUMAN SERVICESSOCIAL SECURITY ADMINISTRATION TOE 710 REQUEST FOR RECONSIDERATION The information on this form is authorized by regulation (20 CFR 404.907 - 404.921 and 416.1407 - 416.1421). While your responses to these questions is voluntary, the Social SecurityAdministration cannot reconsider the decision on this claim unless the information is furnished. (Do not write in this space) NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON (If different from claimant.) SUPPLEMENTAL SECURITY INCOME (SSI) CLAIM NUMBER SPOUSE'S SOCIAL SECURITY NUMBER (Complete ONLY in SSI cases) NAME OF CLAIMANT SOCIAL SECURITY CLAIM NUMBER SPOUSE'S NAME (Complete ONLY in SSI cases) CLAIM FOR (Specify type, e.g., retirement, disability, hospital insurance, SSI, etc.) I do not agree with the determination made on the above claim and request reconsideration. My reasons are: SUPPLEMENTAL SECURITY INCOME RECONSIDERATION ONLY (See reverse of claimant's copy) "I want to appeal your decision about my claim for supplemental security income, SSI. I've read the back of this form about the three ways to appeal. I've checked the box below." EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH SIGNATURE OR NAME OF CLAIMANT'S REPRESENTATIVE CLAIMANT SIGNATURE STREET ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER (Include area code) DATE NON- ATTORNEY TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION See reverse of claim folder copy for list of initial determinations 1. HAS INITIAL DETERMINATION BEEN MADE? SOCIAL SECURITY OFFICE ADDRESS RETIREMENT AND SURVIVORS RECONSIDERATIONS ONLY (CHECK ONE) REFER TO (GN 03102.125) ROUTING INSTRUCTIONS (CHECK ONE) DISTRICT OFFICE RECONSIDERATION NOTE: TAKE OR MAIL COMPLETED COPIES TO YOUR SOCIAL SECURITY OFFICE Form SSA-561-U2 (9-85) EF-PPP-INTERNET (6-95) CLAIMS FOLDER ATTORNEY STREET ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER (Include area code) DATE ADMINISTRATIVE ACTIONS THAT ARE INITIAL DETERMINATIONS (See GN 03101.190, GN 03101.200, and GN 03110.210) NOTE: These lists cover the vast majority of administrative actions that are initial determinations. However, they are notall inclusive. Entitlement or continuing entitlement to benefits; Reentitlement to benefits; The amount of benefit; A recomputation of benefit;A reduction in disability benefits becausebenefits under a worker's compensation law was also received; A deduction from benefits on account of work;A deduction from disability benefits because of claimant's refusal to accept rehabilitation services;Termination of benefits;Penalty deductions imposed because of failure to report certain events; Any overpayment or underpayment of benefits;Whether an overpayment of benefits must be repaid; How an underpayment of benefits due a deceased person will be paid;The establishment or termination of a period of disability; A revision of an earnings record;Whether the payment of benefits will be made,on the claimant's behalf to a representative payee, unless the claimant is under age 18 or legally incompetent;Who will act as the payee if we determine thatrepresentative payment will be made; An offset of benefits because the claimant previously received Supplemental Security Income payments for the same period;Whether completion of or continuation for aspecified period of time in an appropriate vocational rehabilitation program will significantly increase the likelihood that the claimant will not have to return to the disability benefit rolls and thus, whether the claimant's benefits may be continued even though the claimant is not disabled;and Form SSA-561-U2 (9-85) EF-PPP-INTERNET (6-95) 1. 2. 3. 4.5. 6. 7. 8. 9. 10. 11.12.13.14. 15. 16. 17. 18. Title II Nonpayment of benefits because of claimant's confinement in a jail, prison, orother penal institution or correctional facil-for conviction of a felony. Title XVI Eligibility for, or the amount of, Supple-mental Security Income benefits; Suspension, reduction, or termination of Supplemental Security Income benefits; Whether an overpayment of benefits must berepaid; Whether payments will be made, on claimant's behalf to a representative payee, unless the claimant is under age 18,legally incompetent, or determined to be adrug addict or alcoholic; Who will act as payee if we determine that representative payment will be made; Imposing penalties for failing to reportimportant information; Drug addiction or alcoholism; Whether claimant is eligible for special SSIcash benefits;Whether claimant is eligible for special SSI eligibility status; Claimant's disability; and Whether completion of or continuation for a specified period of time in an appropriate vocational rehabilitation program willsignificantly increase the likelihood thatclaimant will not have to return to the disability benefit rolls and thus, whether claimant's benefits may be continued eventhough he or she is not disabled. 1. 2.3.4. 5. 6.7. 8. 9. 10. 11. NOTE: Every redetermination which gives an individual the right of further reviewconstitutes an initial determination. Title XVIII Entitlement to hospital insurance benefitsand to enrollment for supplementary med-ical insurance benefits; Disallowance (including denial of applica- tion for HIB and denial of application forenrollment for SMIB); Termination of benefits (including termina-tion of entitlement to HI and SMI). 1. 2.3. 19. 3. IS THIS REQUEST FILED TIMELY? (If "NO", attach claimant's explanation for delay and attach only pertinent letter, material, or information in social security office.) YES NO DISABILITY DETERMINATION SERVICES (ROUTE WITH ODO, BALTIMORE PROGRAM SERVICE CENTER DISABILITY FOLDER) INTPSC, BALTIMORE OCRO BALTIMORE NO FURTHER DEVELOPMENT REQUIRED (GN 03102.125) REQUIRED DEVELOPMENT ATTACHEDREQUIRED DEVELOPMENT PENDING, WILL FORWARD OR ADVISE STATUS WITHIN 30 DAYS YES NO 2. CLAIMANT INSISTS ON FILING YES NO Case Review Informal Conference Formal Conference DEPARTMENT OF HEALTH AND HUMAN SERVICES SOCIAL SECURITY ADMINISTRATION TOE 710 REQUEST FOR RECONSIDERATION The information on this form is authorized by regulation (20 CFR 404.907 - 404.921 and 416.1407 - 416.1421). While your responses to these questions is voluntary, the Social SecurityAdministration cannot reconsider the decision on this claim unless the information is furnished. (Do not write in this space) NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON (If different from claimant.) SUPPLEMENTAL SECURITY INCOME (SSI) CLAIM NUMBER SPOUSE'S SOCIAL SECURITY NUMBER (Complete ONLY in SSI cases) NAME OF CLAIMANT SOCIAL SECURITY CLAIM NUMBER SPOUSE'S NAME (Complete ONLY in SSI cases) CLAIM FOR (Specify type, e.g., retirement, disability, hospital insurance, SSI, etc.) I do not agree with the determination made on the above claim and request reconsideration. My reasons are: SUPPLEMENTAL SECURITY INCOME RECONSIDERATION ONLY (See reverse of claimant's copy) "I want to appeal your decision about my claim for supplemental security income, SSI. I've read the back of this form about the three ways to appeal. I've checked the box below." EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH CLAIMANT SIGNATURE STREET ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER (Include area code) DATE NON- ATTORNEY TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION See reverse of claim folder copy for list of initial determinations 1. HAS INITIAL DETERMINATION BEEN MADE? SOCIAL SECURITY OFFICE ADDRESS RETIREMENT AND SURVIVORS RECONSIDERATIONS ONLY (CHECK ONE) REFER TO (GN 03102.125) ROUTING INSTRUCTIONS (CHECK ONE) DISTRICT OFFICE RECONSIDERATION NOTE: TAKE OR MAIL COMPLETED COPIES TO YOUR SOCIAL SECURITY OFFICE Form SSA-561-U2 (9-85) EF-PPP-INTERNET (6-95) CLAIMANT'S COPY ATTORNEY STREET ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER (Include area code) DATE SIGNATURE OR NAME OF CLAIMANT'S REPRESENTATIVE HOW TO APPEAL YOUR SUPPLEMENTAL SECURITY INCOME (SSI) DECISIONThere are three different ways to appeal. You can pick the appeal that fits your case. The person who gave you this form can tell how these appeals work. You can have a lawyer, friend, orsomeone else help you with your appeal. Here are the three ways to appeal: 1. CASE REVIEW: You can give us more facts to add to your file. Then we'll decide your case again. You don't meet with the person who decides your case. You can pick this kind of appeal in all cases. 2. INFORMAL CONFERENCE: You'll meet with the person who will decide your case. You can tell that person why you think you're right. You can give us more facts to help prove you're right. You can bring otherpeople to help explain your case. You can pick this kind of appeal in all cases except two. You can't have it if we turned down your application for medical reasons or because you're not blind. Also you can't have it if we're giving you SSI but you disagree with the date we said you became blind or disabled. 3. FORMAL CONFERENCE: This is a meeting like an informal conference. Plus, we can make people come to help proveyou're right. We can do this even if they don't want to help you. You can question thesepeople at your meeting. You can pick this kind of appeal only if we're stopping or lowering your SSI check. You can't get it in any other case. Now you know the three kinds of appeals. You can pick the one that fits your case. Then fill outthe front of this form. We'll help you fill it out. There are groups that can help you with your appeal. Some can give you a free lawyer. We can give you the names of these groups. NOTE: DON'T FILL OUT THIS FORM IF WE SAID WE'LL STOP YOUR SSI DISABILITY CHECK FOR MEDICAL REASONS OR BECAUSE YOU'RE NO LONGER BLIND. WE'LL GIVE YOU THE RIGHT FORM (HA-501-U5) FOR YOUR APPEAL.