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
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:
claimant’s name and address, and
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.