TN 5 (09-22)

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.

 

Need More Help?

 

1. 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.

(11)

2. Visit www.ssa.gov for fast, simple, and secure online service.

3. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.

4. You may also call your local office at (12) (Field Office General Inquiry Line phone number).

(13) (Office name)

(14)

(15)

(16)

(17)

(18)

 

How Are We Doing? Go to www.ssa.gov/feedback to tell us.

 

Fill-ins:

1. 1. 

   Case

   Choice 1: Social Security case

   Choice 2: Supplemental Security Income Case

   Choice 3: Social Security and Supplemental Security Income cases

2. 2. 

   Date of hearing, in the format “January 1, 2022”

3. 3. 

   Time of the hearing

4. 4. 

   Place of the hearing

5. 5. 

   Hours when case can be reviewed

6. 6. 

   Hours when case can be reviewed

7. 7. 

   DHU phone number

8. 8. 

   Hearing office

   Choice 1: If State Agency Hearing Office will hold the hearing: USE “served by your hearing office”

   Choice 2: If Federal Disability Officer will hold the hearing: USE “where we hold the hearing”

9. 9. 

   Travel cost time frame

   Choice 1: 20

   Choice 2: [State time limit]

10. 10. 

    Travel cost time frame

    Choice 1: 20

    Choice 2: [State time limit]

11. 11. 

    If the address of the DHU is not shown anywhere else in this letter, add: The address of the Disability Hearing Unit is: Street Address City, ST ZIP

12. 12. 

    FO Phone contact info

    Choice 1 – Business Number from DOORS (Preferred choice when present)

    Choice 2 – T2 Number from DOORS for T2 Notices (Use only when Business Number is not present)

    Choice 3 – T16 Number from DOORS for SSI Notices (Use only when Business Number is not present)

13. 13. 

    Line 1 of FO Address in DOORS

14. 14. 

    Line 2 of FO Address in DOORS

15. 15. 

    Line 3 of FO Address in DOORS

16. 16. 

    Line 4 of FO Address in DOORS

17. 17. 

    Line 5 of FO Address in DOORS

18. 18. 

    Line 6 of FO Address in DOORS

    Choice 1 - Line 6 of FO Address in DOORS

    Choice 2 – Null (use when address is less than 6 lines)