HA-501

REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE

Download and Print the HA-501

(Take or mail the completed original to 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)

Form Approved OMB No. 0960-0269 - See Privacy Act Notice

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.
And much more...