Check the appropriate block to indicate whether we received the request for AC review
within 65 days of the ALJ’s decision or dismissal. In concurrent claims (Title II
and Title XVI), check “yes” only if the request on both claims is timely. Check “no”
when the request on one claim, or both claims, is not timely, and specify which one(s)
is not.
If you check “no”, obtain a statement that explains the claimant’s reason for late
filing and develop for good cause. The statement should include the following information:
-
•
claimant’s name and address, and
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Forward the statement, any development, and the claim’s folder copy of the Form HA-520-U5,
to the AC. The AC will determine whether the request is timely and whether the claimant
has good cause.