Form Ha 501 U5 PDF Details

When individuals find themselves in disagreement with a decision made regarding their Social Security claims, the Form HA-501-U5 becomes a critical document in their pursuit of justice. Approved by the Social Security Administration's Office of Disability Adjudication and Review, this form, formally known as the Request for Hearing by Administrative Law Judge, is designed to escalate the decision for further review. It embodies an individual's right to argue against determinations that affect their Social Security benefits, allowing them to present their case before an Administrative Law Judge. The form prompts claimants to list not just their basic information, but also to articulate the reasons behind their disagreement with the prior decision. It provides options for the claimant to introduce additional evidence, specify if they wish to appear at the hearing in person, and affirm their rights to legal representation during the process. The instructions included with the form offer clear guidance on how to submit it, either in person or through mail to a local Social Security office, the Veterans Affairs Privacy Act Notice Regional Office in Manila, or any U.S. Foreign Service post, ensuring they retain a copy for their records. By meticulously collecting essential personal and case-related information, the Form HA-501-U5 sets the stage for an appellate process that can significantly impact the lives of Social Security claimants, emphasizing the importance of accuracy, timeliness, and the right to appeal within the administrative framework.

QuestionAnswer
Form NameForm Ha 501 U5
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesssa form 09600269, socialsecurity, VIII, form 09600269

Form Preview Example

SOCIAL SECURITY ADMINISTRATION

Form Approved

OFFICE OF DISABILITY ADJUDICATION AND REVIEW

OMB No. 0960-0269

REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE

 

 

See

(Take or mail the signed original to your local Social Security office, the Veterans Affairs

 

 

Privacy Act Notice

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

-

-

 

 

 

 

 

 

 

 

 

 

 

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.

 

Yes

 

No

Name and address of source of additional evidence:

(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.)

7.Do not complete if the appeal is a Medicare issue.

Check one of the blocks:

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)

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.

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.

8. (CLAIMANT'S SIGNATURE)

 

 

 

(DATE)

 

9. (REPRESENTATIVE'S SIGNATURE/NAME)

 

(DATE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(ADDRESS)

 

ATTORNEY;

 

NON-ATTORNEY;

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

STATE

 

ZIP CODE

 

CITY

 

 

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE NUMBER

 

FAX NUMBER

 

TELEPHONE NUMBER

 

 

 

 

FAX NUMBER

( )

-

 

(

)

-

 

 

(

)

 

 

-

 

 

 

 

 

(

)

-

 

TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION-ACKNOWLEDGMENT OF REQUEST FOR HEARING

10. Request received for the Social Security Administration on

 

 

 

by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Date)

 

 

 

 

 

 

 

 

(Print Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(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

Yes

No

List of legal referral and service organizations provided

13.

Interpreter needed

 

 

Yes

 

 

No

 

Language (including sign language):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Check one:

 

Initial Entitlement Case

 

 

 

 

 

 

Disability Cessation Case

 

 

 

 

 

 

 

 

Other Postentitlement Case

 

 

 

 

16. HO COPY SENT TO:

 

 

 

 

 

 

 

 

 

HO on

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CF Attached:

Title II;

 

 

Title XVI;

 

Title VIII;

 

 

T XVIII;

 

 

Title II CF held in FO

 

 

 

 

 

Electronic Folder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CF requested

 

 

 

 

Title II;

 

 

Title XVI;

 

Title VIII;

 

 

 

T XVIII

 

 

(Copy of email or phone report attached)

 

 

 

 

 

 

 

 

 

 

 

17. CF COPY SENT TO:

 

 

 

 

 

 

 

 

HO on

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title XVIII

 

 

 

 

CF Attached:

 

Title II;

 

 

Title XVI;

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Attached:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. Check all claim types that apply:

RSI only

Title II Disability-worker or child only

Title II Disability-Widow(er) only

SSI Aged only

SSI Blind only

SSI Disability only

SSI Aged/Title II

SSI Blind/Title II

SSI Disability/Title II

Title XVIII

Title VIII Only

Title VIII/Title XVI

Other - Specify:

(RSI)

(DIWC)

(DIWW)

(SSIA)

(SSIB)

(SSID)

(SSAC)

(SSBC)

(SSDC)

(HI/SMI)

(SVB)

(SVB/SSI)

Form HA-501-U5 (02-2011) ef (02-2011) TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS Destroy Prior Editions

Privacy Act Statement

Collection and Use of Personal Information

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), and 1869(b)(1) and (c) (42 U.S.C. 1395ff) of the Social Security Act authorizes us to collect this information. We will use the information you provide to continue processing your claim. The information you provide on this form is voluntary. However, failure to provide all or part of the requested information could prevent us from making an accurate and timely decision on your claim.

We rarely use the information you provide on this form for any purpose other than for the reasons explained above. 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 the Social Security 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, General Services Administration, National Archives Records Administration, 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 and administered benefit programs for repayment of payments or delinquent debts under these programs. The law allows us to do this even if you do not agree to it.

A complete list of routine uses for this information is available in our System of Records Notice entitled, Claims Folder System, 60-0089. This notice, additional information regarding this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at any 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 (02-2011) ef (02-2011)

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