Section 2.61 Request for Review of Hearing Decision/Order

• Library: Elder Law 2015 Forms

This form is available at:

http://www.socialsecurity.gov/forms/ha-520.pdf

SOCIAL SECURITY ADMINISTRATION/OFFICE OF DISABILITY ADJUDICATION AND REVIEW

Form Approved

OMB No. 0960-0277

REQUEST FOR REVIEW OF HEARING DECISION/ORDER (Do not use this form for objecting to a recommended ALJ decision.) (Either the signed original form to the Appeals Court at the address shown below,or take or mail the Signed original to your local Social Security office,the Department of Voferans Affairs Regional Office in Manife,or any U.S. Faveign Service Post and keep a copy for your records.)		See Privacy Ac! Notice
1. CLAIMANT NAME	CLAIMANT SSN
2 WAGE EARNER NAVE, IF DIFFERENT	3 CLAIMANT CLAIM NUMBER, IF DIFFERENT

4. I request that the Appeals Council review the Administrative Law Judge's action on the above clam because

ADDITIONAL EVIDENCE

If you have additional evidence submit it with this request for review. If you need additional time to submit evidence or legal argument, you must request an extension of time in writing now. This will ensure that the Appeals Council has the opportunity to consider the additional evidence before taking its action If you request an extension of time you. should explain the reascn(s) you are unable to submit the evidence or legal argument now If you neither submit evidence or legal argument now now nor within any extension of time the Appeals Council...