TN 5 (09-22)
DI 33010.080 Language for Disability Hearing Scheduling Notice for Domestic Claims — Exhibit
We are writing about your (1) .
We have scheduled a disability hearing for you before a Disability Hearing Officer.
The hearing will be held:
Date: (2)
Time: (3)
Place: (4)
The hearing will start on time. Please do not be late.
You Can Look At Your Case File Before The Hearing
You can look at your case file before the hearing. If you have a representative, that
person can look at your case file too. You can look at the file at the place and date
shown above, between the hours of (5) and (6) .
If you or your representative need to look at your case file before that time, call
the Disability Hearing Unit at (7) . Or, you can call any Social Security office. We will arrange another time and/or
place.
If You Do Not Plan To Come To The Hearing
If you do not plan to come to the hearing, please call the Disability Hearing Unit
or any Social Security office right away. If you do not come, the Disability Hearing
Officer will decide your case using the information in your case file.
If You Need A Different Hearing Place Or Date
If you need a different time or place for the hearing, please call the Disability
Hearing Unit or any Social Security office right away.
Payment For The Cost Of Travel To The Hearing
We can sometimes pay costs for travel to the hearing. You, your representative, and
any witnesses we decide are needed for the hearing can ask us to pay travel costs.
We can pay costs for travel to the place of the hearing if the distance is more than
75 miles one way. We measure the distance from each person's home or office, whichever
the person travels from.
We have a limit on how much we can pay your representative for travel costs. We cannot
pay your representative more than a maximum amount set for the area (8) . If you or your representative want more information about this, please call the
Disability Hearing Unit.
Asking For Payment Of Travel Costs
You or the person asking for payment must give the Disability Hearing Officer proof
of the travel costs. The request for payment and proofs can be given at the hearing.
If you expect to have unusual costs, call the Disability Hearing Unit right away.
Some examples of unusual costs are: ambulance, attendant services, meals, lodging
or taxicabs. The Disability Hearing Officer must approve payment for these unusual
costs before the hearing, unless these costs are unexpected or unavoidable.
Payment For Travel Costs Before The Hearing
If you need payment for travel costs before the hearing, contact the Disability Hearing
Unit right away. If we pay the travel costs before the hearing, you must give the
Disability Hearing Officer proof of the actual costs within (9) days after your trip. If we pay you too much, you will have to pay back the extra
money within (10) days from the day we tell you how much you owe.
Need More
Help?
1. If you have any questions, you should call the Disability Hearing Unit at the telephone
number shown above. We can answer your questions over the phone.
(11)
2. Visit www.ssa.gov for fast, simple, and secure online service.
3. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or
hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.
4. You may also call your local office at (12) (Field Office General Inquiry Line phone number).
(13) (Office name)
(14)
(15)
(16)
(17)
(18)
How Are We Doing? Go to www.ssa.gov/feedback to tell us.
Fill-ins:
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1.
Case
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Choice 1: Social Security case
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Choice 2: Supplemental Security Income Case
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Choice 3: Social Security and Supplemental Security Income cases
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2.
Date of hearing, in the format “January 1, 2022”
-
-
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5.
Hours when case can be reviewed
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6.
Hours when case can be reviewed
-
-
8.
Hearing office
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Choice 1: If State Agency Hearing Office will hold the hearing: USE “served by your
hearing office”
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Choice 2: If Federal Disability Officer will hold the hearing: USE “where we hold
the hearing”
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9.
Travel cost time frame
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Choice 1: 20
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Choice 2: [State time limit]
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10.
Travel cost time frame
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Choice 1: 20
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Choice 2: [State time limit]
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11.
If the address of the DHU is not shown anywhere else in this letter, add: The address
of the Disability Hearing Unit is: Street Address City, ST ZIP
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12.
FO Phone contact info
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Choice 1 – Business Number from DOORS (Preferred choice when present)
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Choice 2 – T2 Number from DOORS for T2 Notices (Use only when Business Number is not
present)
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Choice 3 – T16 Number from DOORS for SSI Notices (Use only when Business Number is
not present)
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13.
Line 1 of FO Address in DOORS
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14.
Line 2 of FO Address in DOORS
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15.
Line 3 of FO Address in DOORS
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16.
Line 4 of FO Address in DOORS
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17.
Line 5 of FO Address in DOORS
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18.
Line 6 of FO Address in DOORS
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Choice 1 - Line 6 of FO Address in DOORS
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Choice 2 – Null (use when address is less than 6 lines)