BASIC (03-01)

DI 33010.080 Language for Disability Hearing Scheduling Notice for Domestic Claims — Exhibit

We are writing about your (1) .

We have scheduled a disability hearing for you before a Disability Hearing Officer. The hearing will be held:

 

Date: (2)

 

Time: (3)

 

Place: (4)

 

The hearing will start on time. Please do not be late.

 

You Can Look At Your Case File Before The Hearing

 

You can look at your case file before the hearing. If you have a representative, that person can look at your case file too. You can look at the file at the place and date shown above, between the hours of (5) and (6) .

If you or your representative need to look at your case file before that time, call the Disability Hearing Unit at (7) . Or, you can call any Social Security office. We will arrange another time and/or place.

 

If You Do Not Plan To Come To The Hearing

 

If you do not plan to come to the hearing, please call the Disability Hearing Unit or any Social Security office right away. If you do not come, the Disability Hearing Officer will decide your case using the information in your case file.

 

If You Need A Different Hearing Place Or Date

 

If you need a different time or place for the hearing, please call the Disability Hearing Unit or any Social Security office right away.

 

Payment For The Cost Of Travel To The Hearing

 

We can sometimes pay costs for travel to the hearing. You, your representative, and any witnesses we decide are needed for the hearing can ask us to pay travel costs. We can pay costs for travel to the place of the hearing if the distance is more than 75 miles one way. We measure the distance from each person's home or office, whichever the person travels from.

We have a limit on how much we can pay your representative for travel costs. We cannot pay your representative more than a maximum amount set for the area (8) . If you or your representative want more information about this, please call the Disability Hearing Unit.

 

Asking For Payment Of Travel Costs

 

You or the person asking for payment must give the Disability Hearing Officer proof of the travel costs. The request for payment and proofs can be given at the hearing. If you expect to have unusual costs, call the Disability Hearing Unit right away. Some examples of unusual costs are: ambulance, attendant services, meals, lodging or taxicabs. The Disability Hearing Officer must approve payment for these unusual costs before the hearing, unless these costs are unexpected or unavoidable.

 

Payment For Travel Costs Before The Hearing

 

If you need payment for travel costs before the hearing, contact the Disability Hearing Unit right away. If we pay the travel costs before the hearing, you must give the Disability Hearing Officer proof of the actual costs within (9) days after your trip. If we pay you too much, you will have to pay back the extra money within (10) days from the day we tell you how much you owe.

 

If You Have Any Questions

 

If you have any questions, you should call the Disability Hearing Unit at the telephone number shown above. We can answer your questions over the phone.

You may also call, write or visit any Social Security office.

If you write any office, please be sure to include your claim number. If you visit any office, please take this letter with you. It will help us answer your questions.

(11)

 

Fill-ins:

1.

Choice 1:

Social Security case

 

Choice 2:

Supplemental Security Income case

 

Choice 3:

Social Security and Supplemental Security Income cases

2.

Date of hearing, in the format “January 1, 1994”

3.

Time of the hearing

4.

Place of the hearing

5.,

  

6.

Hours when case file can be reviewed

7.

DHU phone number