TN 19 (12-11)
GN 03103.020 HA-501-U5 (Request for Hearing by Administrative Law Judge)
A. Form HA-501-U5 (Request for Hearing by Administrative Law Judge)
1. When to use HA-501-U5
Use Form HA-501-U5 Request for Hearing by Administrative Law Judge (ALJ) (see OS 15030.017 HA-501-U5) to request hearings on a reconsideration, a revised reconsideration determination, or any of the other determinations defined in 20 CFR 404.930 (title II) and 20 CFR 416.1430 (title XVI). When possible, complete the Modernized Claims System (MCS) and Modernized Supplemental Security Income Claims System (MSSICS) appeal screens and save the hearing request to the Online Retrieval System (ORS).
For title XVI, refer to SI 04030.020.
NOTE: Initial Disability and Medical Cessation Requests for Hearing – If a hearing level case can be established in the Electronic Disability Collect System (EDCS), process the request for hearing per the instructions in DI 81010.150A.2. and DI 81010.150B or DI 81010.257.
2. Copies of HA-501-U5
There are five copies of the HA-501-U5:
Original (white) is the claim folder copy.
Second (pink) is for the hearing office (HO) file.
Third (yellow) is for field office (FO). When an FO requests a folder from another FO, program service center (PSC), Office of Disability Operations (ODO), or other location, use the FO copy to establish controls and follow-ups.
Fourth (white) is for the claimant. (Mail to the claimant. If in person, give the claimant the claimant's copy of the form.)
Fifth (white) is for the appointed representative. (Mail to the representative. If in person, give the appointed representative the representative’s copy of the form.) If there is no appointed representative, destroy this copy.
For non-disability appeals and disability appeals that you cannot establish in EDCS, fax the HA-501-U5 along with any additional evidence into the Non-disability Repository for Evidentiary Documents (NDRed) and forward it along with any additional evidence to the appropriate office. Do not fax the pink copy of the HA-501-U5. See GN 00301.310 The NDRed Application—Overview and GN 00301.328 Related Business Process Information.
B. Procedure for formal request for hearing
A claimant or any individual listed in GN 03103.010B.1 may formally request a hearing by submitting a completed Form HA-501-U5. See GN 03103.020C for instructions on completing the form. See MSOM MCS 010.002 or MSOM MSSICS 020.001 for instructions on completing the appeal screens when processing the appeal request through MCS or MSSICS. A claimant may also submit a hearing request on an initial disability claim through the iAppeals application. See GN 03101.125 iAppeals Title II and SI 04005.035 iAppeals – Title XVI.
C. Procedure on how to complete the HA-501-U5
1. Items 1 through 4 - Names and Social Security Number (SSN)
Enter the claimant's name and SSN
Enter the name of the wage earner if it is different from the claimant. In title XVI cases, enter the spouse’s name if the claimant and the spouse live together.
Enter the Social Security claim number as it appears on SSA correspondence (i.e. the SSN and beneficiary identification code (BIC) claimant’s claim number if it is different from the claimant’s SSN.
Enter the spouse’s name and claim number or SSN if he or she is not the wage earner. In title XVI cases, enter the spouse’s SSN if the claimant and his or her spouse live together whether the spouse is eligible or is a party to the appeal.
2. Item 5 — Reason for appeal
State the specific reason(s) the claimant believes the determination made on the claim is incorrect. If the claimant needs additional space, use a separate sheet that includes the claimant’s name and claim number. Make copies and attach to each copy of the HA-501-U5.
In an overpayment case, clarify whether the claimant is questioning the determination of the overpayment, the waiver determination, or both.
3. Item 6 — Additional evidence check blocks
Check the appropriate block.
If the claimant submits evidence when requesting a hearing, include his or her name and claim number on the evidence, attach it to the claim folder copy of the HA-501-U5, and write, “evidence attached” in block 6 of the form.
If the claimant does not have the evidence, provide the claimant with a self-addressed envelope to the HO and request that he or she submit it to the HO within 10 days. If the claimant is unable to submit the evidence within 10 days, ask the claimant for the date that he or she will submit it. In item 6 or on a Form SSA-5002 - Report of Contact, briefly describe the type of evidence the claimant will submit and the date the HO can expect to receive it. Attach Form SSA-5002 to the claim folder copy. If the claimant submits the evidence to the FO rather than the HO, forward it immediately to the HO by route slip. If the claimant requests assistance with obtaining evidence, make all reasonable efforts to assist the claimant.
NOTE: Initial Disability and Medical Cessation Requests for Hearing – If a hearing level case can be established in the Electronic Disability Collect System, process the additional evidence per the instructions in DI 81010.135 Storing Non-Medical Evidence in the Electronic Folder.
For non-disability appeals and disability appeals that you cannot establish in EDCS, fax the additional information into NDRed and forward to the appropriate office along with the appeal request. See GN 00301.310 The NDRed Application—Overview and GN 00301.328 Related Business Process Information.
4. Item 7 — “Appearance at hearing” check blocks
Check one of the blocks. Do not complete number 7 if the appeal is on a Medicare issue.
If the claimant does not want to appear at the hearing, check the second block, complete a Form HA-4608 (Waiver of Your Right to Personal Appearance Before an Administrative Law Judge), and attach it to the HO copy. (See GN 03103.030 concerning the waiver of an oral hearing.)
5. Items 8 and 9 — Signature and representation information
You do not need a signature to process the request for hearing. If we have a writing that clearly shows dissatisfaction with an initial determination and it clearly originated with the claimant or any other individual listed in GN 03103.010, process the request.
Item 8 - Enter the claimant’s name, residence address, telephone number, and fax number.
Item 9 – Enter the representative’s, name, address, telephone number, fax number, and check attorney or non-attorney block as appropriate if the claimant has a representative. Obtain an SSA-1696-U4 - Appointment of Representative, or equivalent written statement if the claimant or representative did not previously submit one. (See GN 03910.040.)
6. Item 10 — Acknowledgment of receipt of HA-501-U5 by FO
The FO employee conducting the hearing interview or processing a written request for hearing completes the acknowledgment section of the form.
The request received date should reflect one of the of the following dates:
the date we received the HA-501-U5 or any other writing (indicating a request for a hearing) in the office by walk-in, fax, or email;
the postmark date if we received the HA-501-U5 or any other writing (indicating a request for a hearing) by mail. (See GN 03103.020E)
Attach any writing that you can construe as a request for hearing or expresses dissatisfaction with the reconsideration determination to the HO copy.
Enter the servicing FO’s code (see GN 00904.010 to determine the servicing FO) and the PC’s code in the spaces provided.
7. Item 11 — Timeliness of hearing request check block
Check the appropriate block. (See GN 03101.020 for information on time limits.)
If the claimant did not file the hearing request within 65 days of the reconsideration notice, attach a statement explains the claimant’s reason for late filing of the appeal (see GN 03103.010C.2.) and any material information to the HO copy. The statement can be added to an appeal request, such as the HA-501, or submitted as a separate written statement. The ALJ will decide if there is good cause for late filing of the hearing request.
When the FO receives a hearing request and it is unknown if the claimant filed the request timely, check the Online Retrieval System (ORS) or the Appeal screens for the date of the reconsideration notice. If the request was not filed timely, telephone or send a letter to request that the claimant forward a statement that explains the delay to the HO. Attach a copy of the FO letter or Form SSA 5002 (Report of Contact) to the HO copy. If the FO receives the claimant’s statement, forward it immediately to the HO.
If the request for hearing involves a concurrent title II and title XVI claim with the same issue, check that the request is timely filed if the request on both claims is timely. Check that it is untimely when the request on one or both claims is not timely, and specify on which claim the request is untimely. Follow instructions in the preceding paragraphs for documenting the explanation of the delay.
8. Item 12 — “Claimant unrepresented” check block
If the claimant is not represented, the FO employee explains the right to representation with the claimant as indicated in GN 03910.010B and provides the claimant with a list of legal referral and service organizations. The FO employee checks this block to indicate that he or she provided the list to the claimant.
Do not check this block if:
the claimant is unrepresented and indicates that he or she does not want FO assistance in obtaining representation; or
the claimant is represented,
the request for hearing is being prepared because of correspondence from the claimant or the representative.
9. Item 13 — “Claimant requires interpreter” check block
If a claimant has difficulty communicating in English during the request for hearing interview, the FO employee should ask if the claimant plans to bring an interpreter to the hearing and, if not, if an interpreter is needed.
If a claimant requires an interpreter, the FO employee checks Item 13 and enters the language.
If the claimant states that he or she will bring an interpreter to the hearing, the FO employee prepares and attaches an SSA-5002 Report of Contact outlining the interpreter's qualifications to the HO copy.
10. Item 14 — “Type of action” check block
Check the appropriate box.
If the hearing request concerns waiver of a title XVI overpayment and the recipient alleges that he or she was unaware of reporting requirements, attach any available material (e.g., reporting reminder sheets, copies of notices, copies of check stuffers) that we issued prior to the date of the overpayment to show that the recipient was made aware of the requirements. This action will support SSA's case for possible legal action.
11. Item 15 — “Type of claim” check block
Check the appropriate block(s). If none of the blocks apply, check the “Other” block (e.g., auxiliary claims, non-claim cases such as an appeal of an earnings record determination or waiver of an overpayment, etc.).
12. Item 16 — “Hearing office copy of HA-501-U5” check block
Complete this section in all cases. Send the HO copy to the HO within five business days. (See GN 03103.080.) Enter the HO servicing the claimant's residence address and the date sent. Ensure that all appropriate blocks are checked according to the situation with respect to the claim folder(s) for the case.
When the paper claim folder (s) is available in the FO, send it with the HO copy. Check the “CF Attached” check block, and the appropriate block(s) to show which claim folder(s) is attached.
When the title II or title XVI claim folder(s) is not in the FO, the FO uses established office procedures to request that the folder be sent to the HO within five business days. The FO checks the CF requested block, indicates which folder(s) has been requested, and attaches documentation of the folder request to the HO copy of HA-501-U5.
When the folder is electronic, check the “Electronic Folder” block
13. Item 17 — “Claim folder copy of HA-501-U5” check block
Claim folder in FO
When the FO has the claim folder, the FO employee checks the appropriate blocks to indicate which folder(s) he or she is sending to the HO.
When the FO forwards the claim folder(s) along with the claim folder copy of the HA-501-U5, place the HA-501-U5 in the claim folder and send the folder to the HO. In Supplemental Security Income (SSI) or PSC cases (retirement survivor’s insurance (RSI) and disability), transmit the folder by SSA-636-U3 Transmittal Notice – Hearing Case to the HO. (See GN 03103.110.) The SSA-3583-U2 Transmittal Notice Hearing Case – Disability is used to transmit Office of Disability Operations (ODO) claim folders to the HO (See DI 42010.005).
Claim folder not in office
If the folder is not in the servicing FO, within one business day, forward the claim folder copy of the HA-501-U5 to the HO with a copy of the folder request documentation that explains the claim folder will be sent to the HO.
Attach any pertinent material to the claim folder copy and forward it for association with the HO copy of HA-501-U5.
Check the “Other attached” block and indicate what material is being sent with the claim folder copy. Also, use this block to indicate additional evidence, Form HA-4608, or information related to late filing explanation transmitted with the claim folder copy.
If appropriate, include an explanation that you did not obtain the folder and indicate that you referred the problem to the Office of the Regional Commissioner (ORC).
NOTE: See DI 70005.005 Overview of the Modular Disability Folder (MDF) and DI 81001.005 Certified Electronic Folder (CEF) Overview for instructions on placement of the HA-501-U5 in the MDF and CEF folders. If a brown claim folder is used, place the HA-501-U5 on the right side of the folder.
14. Distribution of the HA-501-U5
Distribute all copies of the HA-501-U5 immediately. Do not hold any copies in the FO other than the “District Office” copy.
D. Informal request for hearing — letter asks for hearing
A claimant, a claimant’s appointed representative, representative payee, or other person on the claimant’s behalf (e.g., member of Congress) may submit a letter to request a hearing.
Based on the letter, the FO or processing center (PC) employee prepares the paper HA-501-U5 or when possible, completes the MCS and MSSICS appeal screens and saves the hearing request to the Online Retrieval System (ORS).
Type the name of the person making the request in signature block. It is not necessary to obtain the claimant's signature.
Under “reasons for disagreement,” enter the following information: the request was made by letter, sender of the letter, and receipt date of the letter.
Attach the original letter to the claim folder copy of the HA-501-U5 and legible copy of the letter to each copy of the HA-501-U5.
Use the date of receipt (walk-in, fax, email) of the letter or the postmark (mail) date as the date of filing for the hearing request.
If you need additional information from the claimant, the FO calls the claimant and conducts an interview over the phone.
If the issue being appealed is disability, see GN 03103.010C.2.
Distribute the copies per in GN 03103.020A.2.
The FO contacts the claimant and explains the right to appear at the hearing per GN 03103.010C.
E. Informal request for hearing-- letter asks for hearing form; no hearing requested
The FO sends an HA-501-U5 to the claimant. If an office other than the servicing FO receives the letter, that office forwards the letter to the servicing FO to send the HA-501-U5.
Include an SSA-1696-U4 (Appointment of Representative) for completion if the claimant has a representative and has not filed an appointment document.
The letter to the claimant or his or her appointed representative requests the information set forth in GN 03103.020C, and reminds the claimant of the requirement that the request be filed within a certain timeframe.
If the claimant files the request for hearing, process it per the instructions in GN 03103.020D in this section.
NOTE: If the claimant submits the hearing request after the 60-day time limit for filing the hearing request, see GN 03103.010C.7. The Hearing Process.
F. Procedure on when to use and how to complete the Spanish Language HA-501-U5-SP
1. When to use the HA-501-U5-SP
If a Spanish-speaking claimant has difficulty with English, have him or her complete the HA-501-U5-SP. See OS 15030.018 HA-501-U5-SP for the Spanish version of the form.
2. How to complete the HA-501-SP
Complete the HA-501–U5-SP per the instructions GN 03103.020C.
Translate the information to English onto the HA-501-U5.
Staple the Spanish and the English copies together.