TN 3 (12-03)

GN 03105.070 FO Folder Retrieval Checklist — Exhibit

Identifying data (complete all applicable items):

  1. 1. 

    N/H Name:                    SSN:                 

  2. 2. 

    Appellant Name (if different):                          

  3. 3. 

    Cross reference SSN/BOAN (if any):                

  4. 4. 

    Type of Case (circle one):  Hearing   AC Review   Civil Action

  5. 5. 

    Hearing Request Date:                 

  6. 6. 

    Date HA-501 (HO copy) forwarded to ODAR:                

  7. 7. 

    Type of Folder(s) Needed (check all applicable):

    ( ) SSI Aged

    ( ) SSI Blind/Disabled

    •  

      ( ) current folder ( ) prior folder

    ( ) T2 DI B

    •  

      ( )current folder ( ) prior folder

    ( ) DWB

    ( ) RSI

  8. 8. 

    ( ) Other       

    Query Information(show pertinent information and attach copies):

    1. a. 

      PCACS date:                shows:                

    2. b. 

      SSI2 date:                shows:                

    3. c. 

      HA04 date:                shows:                

    4. d. 

      Other type:                 date:          shows:                

    Field Office Actions

    1. a. 

      Component contacted:                

    2. b. 

      Date of initial request:                

    3. c. 

      Date of followup request:                

    4. d. 

      Office making referral:                

    5. e. 

      Office contact person:                

    6. f. 

      Office telephone number:                

    7. g. 

      Date referred to ORC:                

 


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0203105070
GN 03105.070 - FO Folder Retrieval Checklist — Exhibit - 12/23/2003
Batch run: 04/25/2016
Rev:12/23/2003