SSA-561

Request For Reconsideration

Download and Print the SSA-561

NAME OF CLAIMANT

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON (If different from claimant.)

CLAIMANT SSN      -   -

CLAIMANT CLAIM NUMBER (if different from SSN)
Form SSA-561-U2 (6-2012) ef (06-2012)
Prior Edition May Be Used Until Exhausted -  -

SUPPLEMENTAL SECURITY INCOME (SSI) OR SPECIAL VETERANS BENEFITS (SVB) CLAIM NUMBER

SPOUSE'S NAME (Complete ONLY in SSI cases)

SPOUSE'S SOCIAL SECURITY NUMBER (Complete ONLY in SSI cases)

CLAIM FOR (Specify type, e.g., retirement, disability, hospital /medical, SSI, SVB, etc.)

I do not agree with the determination made on the above claim and request reconsideration. My reasons are:

SUPPLEMENTAL SECURITY INCOME OR SPECIAL VETERANS BENEFITS RECONSIDERATION ONLY

(See the three ways to appeal in the How To Appeal Your Supplemental Security Income (SSI) Or Special Veterans Benefit (SVB) Decision instructions.)
"I want to appeal your decision about my claim for Supplemental Security Income (SSI) or Special Veterans Benefits (SVB). I've read about the three ways to appeal. I've checked the box below."

And much more...