TN 5 (07-12)
GN 03104.200 Preparation of Form HA-520-U5 (Request for Review of Hearing Decision/Order)
A. Processing the Form HA-520-U5
The field office (FO) is responsible for the proper completion and timely distribution of the Form HA-520-U5.
NOTE: Process requests for Appeals Council (AC) review of disability issues per the instructions in DI 12020.001B.3.
B. National 800 Number Network (N8NN) instructions for the Form HA-520-U5
National 800 Number Network agents follow the instructions for handling a request for AC review in TC 03001.020.
C. Instructions for completing the Form HA-520-U5
1. Reason for appeal – number 4
Enter the reason(s) the claimant disagrees with the ALJ’s action. If the claimant needs additional space, he or she may use a separate sheet of paper and attach a copy to each copy of the Form HA-520-U5.
2. Claimant’s and appointed representative’s information – number 5 and 6
Enter the claimant’s address, telephone number, and fax number.
If the claimant has an appointed representative, enter the representative’s name, address, telephone number, and fax number.
We do not require a signature to file an appeal. Therefore, the claimant and representative are not required to sign the form. Obtain an SSA-1696-U4 (Appointment of Representative) if the claimant or representative has not previously filed one with us. For information about appointment of a representative, see GN 03910.040.
3. Acknowledge the request for AC review – number 7
The employee who prepares or receives the form must complete the box marked for 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:
date of in-office filing, or
postmark or date-stamp on the Form HA-520-U5, or
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.
Enter the servicing FO code.
Attach any letter, fax, email message, or other written document, that could be construed as a request for AC review or that expresses dissatisfaction with the ALJ action to the claims folder copy of the Form HA-520-U5.
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.
4. Timeliness of request for AC review – number 8 and 9
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 or both claims is not timely, and specify which one(s) is not.
If you check “no,” obtain a statement that explains that claimant’s reason for late filing and develop for good cause. The claimant can add a good cause statement to the appeal request, such as the HA-520-U5, or submit as a separate written statement. The statement should include the following information:
Forward the statement and any development along with 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.
5. Type of action – number 10
Check whether the request for AC review is for initial entitlement, termination, or other.
6. Type of claim – number 11
Check all claim types that apply. If the request for review involves an issue not relating to a claim type (for example; HA auxiliary claims, non-claim cases (such as earnings record postings), denial of waiver of recovery of overpayment) specify the reason next to “Other.”
NOTE: Make only one entry in this section.
7. Additional evidence
The claimant should submit any document(s), or other evidence that he or she wants the AC to consider, with the AC review. If evidence dated after the ALJ decision is relevant to the period before the ALJ decision, the AC will consider it with respect to the AC review. Otherwise, the AC will return the evidence to the claimant with a notice explaining that the claimant may file a new application with a protective filing date back to the date of the request for review.
Claimant’s additional evidence
Attach any evidence to the “claims folder” copy of the Form HA-520-U5.
Annotate “evidence attached” on each copy of the Form HA-520-U5.
Annotate the claimant's name and social security number on any evidence that the claimant sends to the FO.
If the claimant is unable to submit the additional evidence at the time he or she files the request for AC review, advise the claimant to forward any additional evidence, marked with his or her name and SSN, within 15 days to the address listed in GN 03104.200D.1. of this section.
Describe briefly, in the “Reasons for Disagreement” section, the type of evidence the claimant will submit.
If the claimant submits evidence after filing the request for AC review, annotate the evidence with claimant’s name and SSN and forward it directly to the Office of Appellate Operations (OAO) at the address listed in GN 03104.200D.1. of this section.
Do not delay forwarding the request for AC review pending submission of evidence.
If the claimant's statement or other information indicates any development leads which might permit a favorable decision, record the information on an SSA-5002 (Report of Contact) and attach a copy of it to each copy of the Form HA-520-U5 (except for the claimant’s copy).
D. Distribution of the Form HA-520-U5
Distribute copies of the Form HA-520-U5 immediately. Do not delay the release of the form pending submission of additional evidence.
1. Claims folder copy
Send the claims folder copy of the Form HA-520-U5, and any available additional evidence, to the Office of Analytics, Review, and Oversight (OARO) within 1 business day of the date it is filed to the following address:
OARO, Office of Appellate Operations
5107 Leesburg Pike
Falls Church, VA 22041-3255
Non-disability request for AC Review
Fax the request for AC review and additional evidence into the Non-disability Repository (NDRED).
Place the request for AC review along with any additional evidence into the paper folder and forward to the address in GN 03104.200D.1.
2. Claimant copy
Give or mail a copy of the form to the claimant.
3. Representative copy
Give or mail a copy of the form to the claimant's appointed representative. If the claimant is not represented, destroy this copy.
4. Servicing FO copy
Destroy this copy of the form.
5. Hearing office file copy
Send a copy of the form to the ALJ who conducted the hearing. Destroy this copy if there is a legible copy of the request for AC review in the certified electronic folder (disability appeals) and NDRED (non-disability appeals).
E. Instructions for updating the Development Worksheet (DW01) or Modernized Development Worksheet (MDW)
Record the date we received the Form HA-520-U5 on the DW01 or MDW.
Record all subsequent actions including all contacts with the claimant or representative on the DW01 or MDW.
Post the AC decision and date on the DW01 or MDW.