Provide the claimant's name.

Provide the claimant's SSN.

Provide the claim number only if the claim is based on or requires earnings information that is different from the claimant’s SSN record. The claimant may have a different claim number when he or she:

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  Applies for benefits on another person’s work record (a wage earner). When this is the case, enter the wage earner’s SSN; or

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  Applies for benefits on both the claimant’s own work record and on another person’s work record. When this is the case, enter the other person’s SSN, or

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  Applies for supplemental security income (SSI) and is married. When this is the case, enter the spouse’s SSN regardless of whether the spouse is eligible, or is a party to the appeal.

Provide the reason(s) the claimant disagrees with the hearings level actions. If the claimant needs additional space, the claimant may use a separate sheet of paper and attach a copy to the form HA-520.

Section - Additional evidence:

The claimant may submit any additional evidence not previously submitted or argument to the AC that relates to the period on or before the date of the hearing decision, they must inform the AC about it or submit the evidence or other documents along with the request for AC review.

Additionally, the form HA-520 allows a claimant or an appointed representative to request an extension of time (EOT) to submit additional evidence or argument to the AC. The HA-520 and i520 include the option to request an EOT on the form themselves by checking the box for “Please grant me an extension of time to submit evidence or argument.”

For an initial EOT request, the AC generally provides the claimant or the appointed representative 25 days from the date of the notice granting the EOT.

IMPORTANT: Ensure the claimant’s SSN is on any letter or material the claimant submitted with the request. The request for review should be forwarded in a timely manner.

Do not delay forwarding the request for review to wait for potential submission of additional evidence.

If the claimant submits neither evidence nor a legal argument at the time of request for AC review or within any extension of time the AC grants, the AC will take its action based on the evidence available in file.

Enter the claimant’s mailing address, telephone number, and fax number.

The claimant can have a representative to help them when they do business with Social Security. The representative can be an attorney or a non-attorney. If the claimant has already appointed a representative, use this section to give the name and contact information of the representative. If the claimant would like to appoint a representative, they may complete this section to provide that individual’s contact information, but they also must complete and submit form SSA-1696 (Claimant’s Appointment of a Representative) before we can recognize the individual as their representative. For information about appointment of a representative, see GN 03910.040

The FO who prepares or receives the form must complete the box marked for completion by SSA. If an office other than the servicing FO completes it, annotate the FO code with a brief explanation.

Show the earliest of the following dates as the date filed:

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  date of in-office filing, or

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  postmark or date-stamp on the form HA-520, or

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  postmark or date-stamp on the letter or any other written document, or the date on the fax message or email message that requests or indicates intent to file a request for AC review.

Attach the postmarked envelope to the form HA-520 or other letter, if you use the postmark to establish the date of filing.

EXCEPTION: If the letter, fax, email message, or other written document is marked “confidential,” do not make the additional copies. The AC determines if the material can be included in the official record.

Check the appropriate box to indicate whether we received the request for AC review within 65 days of the hearings level decision or order of dismissal. For more information on appeal period, see GN 03101.010A.1.

If you check “no,” attach the good cause statement (if any) that explains the claimant’s reason for late filing and any FO documentation concerning the delay. The claimant can add a good cause statement to the form HA-520, or submit as a separate written statement. The statement should include the following information:

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  claimant's SSN, name, address, and

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  reason for the delay.

IMPORTANT: Do not delay forwarding the request for review to the AC to wait for a good cause statement. The AC has the authority to develop for or decide whether there is good cause to extend the time for filing a request for review. For more information on good cause at AC review level, see GN 03101.020D.2.

Check whether the request for AC review relates to an initial entitlement or termination or other.

Check all claim types that apply.