Section 2.60 Request for Hearing by Administrative Law Judge

• Library: Elder Law 2015 Forms

This form is available at:

http://www.socialsecurity.gov/forms/ha-501.pdf

SOCIAL SECURITY ADMINISTRATION Form Approved

OFFICE OF DISABILITY ADJUDICATION AND REVIEW _ OMB No. 0960-0269

REQUEST FOR HEARING BY ADMINISTRATIVE LAW JUDGE (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)			See Privacy Act Notice
1. Claimant Name	2. Claimant SSN	3. Claim Number, if different
4.I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination because:

An Administrative Law Judge of the Social Security Administration's Office of Disability Adjudication and Review or the Department of 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.

5. I have additional evidence to submit. [ ] Yes [ ] No

Name and source of additional evidence, if not included.

6. Do not complete if the appeal is a Medicare issue. Otherwise, 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)

Submit your evidence to the hearing office within 10 days. Your servicing Social Security office will provide the hearing office's address. Attach an additional sheet if you need more space.

Representation: You have a right to be represented at the hearing. If you are not represented, your Social...