Last Update: 9/2/2005 (Transmittal I-2-62)
HA 01270.096 Sample - Examination
of Evidence
Renumbered from HALLEX section I-2-7-96
EXAMINATION OF EVIDENCE
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In the case of
_______________________________
(Claimant)
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Claim for
______________________________
(Social
Security Number)
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_______________________________
(Wage
Earner)
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_______________________________
(Social
Security Number)
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DESCRIPTION OF ADDITIONAL EVIDENCE
(List Additional Evidence Here)
A. Claimant to check appropriate statements:
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____
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I examined the above listed evidence
and have no comments to make.
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____
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I examined the above listed evidence
and my comments are as follows: (Use reverse side if necessary.)
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____
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I have no further evidence to submit.
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____
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I am submitting the following evidence:
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____
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I do not wish to request a supplemental
hearing to discuss this evidence.
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____
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I wish to request a supplemental hearing
to discuss this evidence.
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____
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I do not wish to question, either orally
or in writing, the author(s) of this (these) report(s).
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____
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I wish to question, either orally or
in writing, the author(s) of this (these) report(s).
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__________________
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__________________
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Security Employee)
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(Date)
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B. The claimant did not respond to our 10-day letter.
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__________________
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__________________
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(Signature/Title of
Social Security Employee
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(Date)
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